Please complete the form below to share information about a new product. Last Name: First Name: Company: Position Title: Phone: Email Address: Are you affiliated with a GPO? Yes No Are you Vendormate Compliant? Yes No Are you an existing vendor with Mosaic? Yes No Product Information Product Information Vendor: Manufacturer: Vendor Catalog #: Manufacturer #: Description (Limit 30 characters): Buy Unit of Measure: Unit Cost: UNSPC Code: HCPCS Code: Does it contact latex? Yes No List all the areas/departments that could use this product: For what procedure/when will this product be used? Is the product reimbursable? Yes No What is the CPT code? List advantages of newly requested product: Will new product be used in conjunction with a piece of equipment? Yes No If yes, please provide further detail: Name of Mosaic employee with whom you've discussed this product: Will new product/equipment require software? Yes No Who are your competitors in the market? Word verification Refresh captcha Submit Request