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Institutional Request Form

Please complete the form below and we will contact you with more information.
Practice or Institution Name: *
Contact Name: *
Country: *
Address: *
Address 2:
City: *
State: *
Postal Code: *
IP Address:
Number of users who will be accessing this site: *
Do you currently have another format of Bates Video product (DVDs, streaming/institutional version, etc)?

Admin Contact Name: *
Admin Contact Email: *
Admin Contact Phone: *
Technical Contact (please provide if available):
Technical Contact Name:
Technical Contact Email:
Technical Contact Phone:
Additional Note (optional):
* Required fields