Requestor Information s1

Lab Request Form

Requestor Information Company:

Name of Requestor: Title:

Phone No.: Fax No.:

Billing Address: Email:

Site Visit (Please call to schedule)

Lab Information

Requested Event Date(s):

Lab Start Time: ½ day ( < 4 hours) Full day ( ≥ 4 hours)

No. of Lab Stations: No. of Registrants:

Instrumentation

General Hand Instruments

Power Tools

Compressed Air (for customer supplied pneumatic devices)

Service and Equipment Needs

Lab Conference Room

Teleconferencing

Video Camera

C-Arm Quantity & Type: Lead Apron Quantity:

Specific Date(s) and Hours of C-Arm Technician:

Arthroscopy System Size of Scopes: Other Specifics: Quantit Catering y: Breakfast Lunch Dinner Special Diet

LAB REQUEST FORM PAGE 1 OF 2 DOC 10314-4 REV. A MER #

Specimen Information

Arrangements: Paragon

Customer Specimen Supplier: Delivery Date & Time:

Shipping Service: Pick-up Date & Time:

Type of Specimen Quantity Description (i.e. Anatomy Portion, Sex, Age, Surgeries)

Shoulder

Hand/Wrist

Foot/Ankle

Specimen Positioning Device Needed (Specify Set-up Directions Below)

Special Instructions:

Specimens Set-up by: (exact time)

Required Event Materials Please attach the following or submit 48hrs in advance of your scheduled event:

Agenda/Program Information

Registration List

Requestor’s Signature

Today’s Date: Signature:

Thank you for your interest in the Paragon Medical Bioskills Lab. Please allow up to two (2) business days for Event confirmation via a Budgetary Quote. If you have any questions or changes, please contact Stacy Leeper, Paragon Medical Bioskills Lab Coordinator, at 574-594-2140. For Internal Use Only Date Received:

LAB REQUEST FORM PAGE 2 OF 2 DOC 10314-4 REV. A