Phone: 800.624.8832

Protected Lead Registration

Leads should be submitted as soon as they are identified, so they are protected.

Please complete the form below to submit your protected leads.

Reseller Name(Required)

Submitted By(Required)

First Last

Submission Date(Required)

Add protected lead

Date Registered(Required)

Lead Name (Practice/Company)(Required)

Contact Name(Required)

First Last

Specialty(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

Products(Required)

Products - Other(Required)

# of Providers(Required)

Estimated VAR Cost(Required)

Estimated Invoice Date(Required)

Lead Status(Required)

Lead Source(Required)

Additional Comments

MicroMD Division Headquarters: 6715 Tippecanoe Road, Building C, Suite 4C, Canfield, Ohio 44406 — Sales inquiries call 1-800-624-8832 — All other telephone inquiries: 1-330-758-8832