Surgical Skills Laboratory Request Form
Contact Information
*
Company Name
*
Phone Number
*
Director/Contact Name
*
Title
*
Email Address
Invoice Information
*
Street Address
Address Line 2
*
City
*
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Washington DC
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Zip Code
*
Phone Number
*
Attention:
*
Email Address
Program Lab Information
*
Course Title
*
Perferred Course Date
*
Alternate Course Date
*
Number of Days
*
Start Time
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
*
End Time
8:00 AM
8:30 AM
9:00 AM
9:30 AM
10:00 AM
10:30 AM
11:00 AM
11:30 AM
12:00 PM
12:30 PM
1:00 PM
1:30 PM
2:00 PM
2:30 PM
3:00 PM
3:30 PM
4:00 PM
4:30 PM
5:00 PM
5:30 PM
6:00 PM
6:30 PM
7:00 PM
7:30 PM
8:00 PM
8:30 PM
9:00 PM
9:30 PM
10:00 PM
*
Number of
Surgeons
*
Number of
Fellows/Residents
*
Number of
Reps
Conference Room Reservation
*
All Conference Facilities include A/V capabilities
Day 1
Day 2
Day 3
Day 4
Day 5
Not Required
Large Conference Room (seats 50 - 60)
Small Conference Room (seats 6 - 10)
Anatomical Specimens
Specimens Required
Quantity
Knee Specimen (Mid-femur to mid tibia/fibula)
Hip Specimen (Hemi-Pelvis with Proximal Femur)
Arm Specimen
Shoulder Specimen (mid-humerus with scapula)
Elbow/Wrist/Hand Specimen
Foot/Ankle Specimen
Special Request:
Equipment
Video Towers
Quantity
Arthroscopy Video Towers
Hall Micro Power
Medium Speed Drill
1
2
Sagittal Saw
1
2
Reciprocating Saw
1
2
Oscillating Saw
1
2
Hall Large Power Drills/Saws
Oscillating saw
1
2
3
4
5
6
7
8
9
10
Reciprocating saw
1
2
3
4
5
6
7
8
9
10
Large Drill
1
2
3
4
5
6
7
8
9
10
Power Attachemnts
Jacobs Chuck (6.5mm)
1
2
3
4
5
6
7
8
9
10
Pin Driver ( 1.8mm - 4mm/.071" - .156" )
1
2
3
4
5
6
7
8
9
10
AO adapter (Quick Connect)
1
2
3
4
5
6
7
8
9
10
Zimmer/Hudson 5:1 Reamer (Large)
1
2
3
4
5
6
7
8
9
10
Zimmer/Hudson (Small)
1
2
3
4
5
6
7
8
9
10
Instrumentation
Instrumentation
General Arthroscopic Set
1
2
3
4
5
General Dissecting Set
1
2
3
4
5
Instrumentation
General Small Joint Set
1
2
3
General Large Joint Set
1
2
3
If you are providing instrumentation, please specify:
If you need
OTHER
instrumentation, please specify:
*
Is Radiology Support required? -
Mini C-Arm Usage
Yes
No
Miscellenous
*
Do you need Catering provided?
Yes
No
Meal Planning
Number of People
Meal Time
Breakfast
Morning Break
Lunch
Afternoon Break
Dinner
Other specifications/details:
*
Indicates Response Required