CMT SAMPLE PRODUCT APPLICATION

Name(Required)

First Last

Occupation / Title(Required)

License Number(Required)

Facility Name

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Website(Required)

Email(Required)

Phone(Required)

CMT Sample Program Options - Please choose One Option

Receive CMT Branded Products OR

Receive 50% of 2 accessory items, such as dilators, binders, and/or lubricants.

Sample Products Policy Overview - Please Read In its Entirety(Required)

CMT has developed a policy to help facilities by providing free CMT branded products to use as display with their patients. To get these free samples, as well as the 50% demo discount, facilities need to be currently enrolled in our Rx Pad Discount Program. If you are not enrolled in our Rx Pad Discount program, please click on the link below under, "Not Enrolled in our Rx Pad Discount Program." This package of products is made available at no cost upon completion and return of this application. Also, although the samples are at no cost, you will be responsible for the shipping. Please provide your CMT Facility ID below. Please note one sample package per Facility ID only.

Non CMT Branded Products

If you are not interested in CMT branded products, we do offer a 50% discount on any of our other over-the-counter products commonly used with patients. For example, dilators, binders, and/or lubricants.

Our 50% demo discount is good for 2 accessory items. If interested, please click the check box below and send an email to Janet at info@cmtmedical.com for ordering.

CMT Branded Products (Valued at over $215) The package of products that are available are:

Release is a rectocele tool designed to provide relief by providing a more anatomical positioning so that bowels can be emptied with ease.

Serenity Therapy Massage Tools, is designed to reach internal musculature with the pelvic floor region to help massage muscles.

Pop QMs is a measuring stick that allows Clinicians the ability to determine the amount of hiatal ballooning in patients with an increased risk of prolapse.

Elevate Toileting Stool is a device used to help ease constipation and prevent hemorrhoids’ as a result of straining.

V-Tone Vaginal Weights are a set of weights that are inserted into the vagina to help strengthen the pelvic floor muscles.

CMT Ball, Band and Clip Set is used to target the inner thighs and abdominal muscles.

Embrace Support Belt proven to help reduce sacroiliac joint pain, inflammation, promotes better posture and increases independent functional engagement all while being discreetly worn under clothing.

Choose One Size for Embrace Belt Size Small Size Medium Size Large Size XLarge

Please let us know what size of the Embrace Support Belt you would like.(Required)

Not enrolled in our no-cost Rx Pad Discount Program? Simply cut and paste the link below to be directed to the page to get started.

https://www.cmtmedical.com/rx-pad-program/

QUESTIONNAIRE

In an average month, how many new patients with urinary incontinence do you see?(Required)

In an average month, how often do you recommend pelvic floor weights (vaginal weights) to your patients?(Required)

In an average month, how many new patients with pelvic pain do you see?(Required)

In an average month, how many new patients with interstitial cystitis (IC) or painful bladder syndrome (PBS) do you see?(Required)

In an average month, how many times do you recommend vaginal dilators to a patient?(Required)

In an average month, how many times do you recommend a pelvic wand to a patient?(Required)

In an average month, how many times do you recommend a vulvar balm (or coconut oil) for vulvar dryness or irritation?(Required)

If you like our products, would you be interested in selling our products in our clinic/facility?(Required)

Are you currently ordering from CMT?(Required)

What else should we know about you and your facility?

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