ThinPrep System Information Request for Medical Professionals

Medical Professionals Information Request

To receive more information about the ThinPrep® System, please complete and submit the following form.

*Required Field

*First Name:

*Last Name:

Job Title:

*Medical Specialty:

	OB/GYN			General/Family Practitioner
	Internist			Medical Oncologist
	Gynecologic Oncologist			Surgeon
	Surgical Oncologist			Radiologist
	Radiation Oncologist			Gynecologist
	RN/NP			Cytological Pathologist
	Preventive Medicine			Other

Institution:

*Address:

*City:

*State:

*ZIP:

Phone:

Fax:

*Email:


Please provide the following information:
Estimated number of...	Your Practice	Your Institution
Pap tests performed/month:
ThinPrep Pap Tests performed/month:
Which lab(s) process your tests?