Online Design Form - Chronic EMG Patch

Chronic EMG Patch
× Fields marked with (*) are required
    Contact Information
  1. Principal Investigator name:(*)
    Please type your Principal Investigator name.
  2. Institution Name:(*)
    Please type your Institution name.
  3. Institution Address:
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  4. Telephone Number:
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  5. Email:
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  6. Researcher’s name:(*)
    Please type your Researcher’s name.
  7. Researcher’s email:(*)
    Please type your Researcher’s email.
  8. General Specifications
    Dual Contact Options - Single or Double Sided
    Multi-Contact Options
  9. 1. Please select number of contacts (n):(*)
    This field is required
  10. Please specify number of Multi contacts
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  11. 2. Width of the patch (y1):(*)
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  12. Invalid Input
    Please specify width of the patch
  13. 3. Height of the patch (y2):(*)
    This field is required
  14. Invalid Input
    Please specify height of the patch
  15. 4. Distance between contacts (x1):(*)
    This field is required
  16. 5. Length of the contacts (X2) :(*)
    This field is required
  17. 6. Distance between pair of contacts (X3):(*)
    This field is required
  18. Your Custom Design

    If distance is different for multiple contacts, please provide diagram showing distance:

  19. Upload a file:
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    Allowed file types: bmp, gif, jpg, jpeg, png, doc.

  20. 7. Please select type of patch:(*)
    This field is required
  21. 8. Length of Teflon insulated stranded SS lead wires (S):(*)
    This field is required
  22. This field is numeric
    Please specify length of Teflon
  23. Connector and Headstage
  24. 9. Connector(s):(*)

    This field is required
  25. Provided by the customer
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  26. 10. Provide us with the brand and model of your recording and/or stimulation system (*)
    This field is required
    Please include headstage and any special configuration
  27. About your order
  28. How many EMG Patch design do you wish to order(*)
    Numeric Value
  29. Special requirements
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  30. How should we contact you?

  31. How did you find us?

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