<p> MER #</p><p>Lab Request Form</p><p>Requestor Information Company: </p><p>Name of Requestor: Title: </p><p>Phone No.: Fax No.: </p><p>Billing Address: Email: </p><p>Site Visit (Please call to schedule)</p><p>Lab Information</p><p>Requested Event Date(s):</p><p>Lab Start Time: ½ day ( < 4 hours) Full day ( ≥ 4 hours)</p><p>No. of Lab Stations: No. of Registrants: </p><p>Instrumentation</p><p>General Hand Instruments</p><p>Power Tools </p><p>Compressed Air (for customer supplied pneumatic devices)</p><p>Service and Equipment Needs</p><p>Lab Conference Room</p><p>Teleconferencing</p><p>Video Camera</p><p>C-Arm Quantity & Type: Lead Apron Quantity:</p><p>Specific Date(s) and Hours of C-Arm Technician: </p><p>Arthroscopy System Size of Scopes: Other Specifics: Quantit Catering y: Breakfast Lunch Dinner Special Diet</p><p>LAB REQUEST FORM PAGE 1 OF 2 DOC 10314-4 REV. A MER #</p><p>Specimen Information </p><p>Arrangements: Paragon </p><p>Customer Specimen Supplier: Delivery Date & Time: </p><p>Shipping Service: Pick-up Date & Time:</p><p>Type of Specimen Quantity Description (i.e. Anatomy Portion, Sex, Age, Surgeries)</p><p>Head</p><p>Shoulder</p><p>Torso</p><p>Elbow</p><p>Hand/Wrist</p><p>Hip</p><p>Knee</p><p>Leg</p><p>Foot/Ankle</p><p>Other</p><p>Specimen Positioning Device Needed (Specify Set-up Directions Below)</p><p>Special Instructions:</p><p>Specimens Set-up by: (exact time)</p><p>Required Event Materials Please attach the following or submit 48hrs in advance of your scheduled event:</p><p>Agenda/Program Information </p><p>Registration List </p><p>Requestor’s Signature</p><p>Today’s Date: Signature: </p><p>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:</p><p>LAB REQUEST FORM PAGE 2 OF 2 DOC 10314-4 REV. A</p>