Trauma and Extremities Lab Request and C-19 Lab Request Form Addendum

Trauma and Extremities Lab Requests should have preliminary AVP approval prior to submitting any requests.

The Lab Request form is designed to allow the sales representative to provide the required information for lab approval and execution for Trauma and Extremities.

 **ADDITIONAL LAB REQUESTS MUST HAVE A 10 BUSINESS DAY LEAD BEFORE THE EVENT**

**ALSO, THIS SUBMISSION IS ONLY A REQUEST AND NOT A GUARANTEED APPROVAL FOR A DATE**

If you are requesting a lab at a Smith-Nephew facility, please register your information on VSP/CEV registration here: https://orthomeetings.com/vsponsight-registration/.


Local labs: Covid 19 CMT guidelines:
3 Stations Max
1 proctor HCP per station
2 learner HCP per station
3 S+N Employees per station (Including CES)

If yes, provide date of surgery:*
Is SN Consultant needed for this event? *
If Yes, Professional Education will determine Faculty Choices.
If yes, please attach the document detailing C-19 policy updates via email with this form.
Upload Documentation:*
No File Chosen
File uploads may not work on some mobile devices.
Identify step to ensure safe environment for S+N employees & customers*
If yes, *
Please provide documents supporting specimen related protocols.*
No File Chosen
File uploads may not work on some mobile devices.
Today's Date
:  
Place costs / estimates / additional notes here.

Trauma and Extremities Lab Request and AVP Selection

Trauma and Extremities requests should be addressed to your Sales Manager, DOS or AVP.

If you are requesting a lab at a Smith-Nephew facility, please register your information on VSP/CEV registration here: https://orthomeetings.com/vsponsight-registration/.


Lab Info

Your Contact Information

Name*

THE DATE REQUESTS BELOW ARE ONLY A REQUEST AND NOT A GUARANTEE OF DATE OR APPROVAL

Requested Lab Date #1*
Requested Start Time*
:  
Requested End Time*
:  

A 30 DAY MINIMUM IS REQUIRED FOR REQUESTING A C-ARM


RETURN LABELS ARE INCLUDED IN YOUR WAREHOUSE SHIPMENT AND YOUR RETURN EQUIPMENT MUST BE RECEIVED BY THE WAREHOUSE WITHIN 3 BUSINESS DAYS FOLLOWING YOUR LAB


PLEASE MARK ALL BROKEN OR MISSING INSTRUMENTS BEFORE RETURN

Pick Your AVP*
Choose CES (Central)*
Choose Trauma DOS (Central)*
Choose Full-Line DOS (Central)
Choose CES (West)*
Choose Trauma DOS (West)*
Choose Full-Line DOS (West)
Choose CES (East)*
Choose Trauma DOS (East)*
Choose CES (East - EO)*
Choose Trauma DOS (East - EO)*
Choose CES (West - EO)*
Choose Trauma DOS (WEST - EO)*

Lab Type

Trauma Type of Meeting*

Upper Extremity Arthroplasty

Upper Extremity Selections:

Lower Extremity Arthroplasty

Lower Extremity Selections:

Upper Extremity Deformity

Deformity
TSF Indication / Procedure
Modular Rail System Indication / Procedure

Upper Extremity Arthrodesis

Upper Extremity Arthrodesis Selections:

Lower Extremity Arthrodesis

Lower Extremity Arthrodesis Selections:
Choose Lower Extremity Arthrodesis Indication/Procedures for TSF
Choose Lower Extremity Arthrodesis Indication/Procedures for Ilizarov
Choose Lower Extremity Arthrodesis Indication/Procedures for Hat-Trick

Lower Extremity Deformity

Choose Lower Extremity Deformity Category
Choose Lower Extremity Deformity Indication/Procedures for TSF
Choose Lower Extremity Deformity Indication/Procedures for Ilizarov
Choose Lower Extremity Deformity Indication/Procedures for the Modular Rail System
Choose Lower Extremity Deformity Indication/Procedures for Hat-Trick

Lower Extremity Trauma

Lower Extremity Trauma
IM-Nails
External Fixation
Plates and Screws
InvisiKnot
Choose Lower Extremity Trauma Category
Choose Lower Extremity Trauma Indication/Procedures for TSF

Lower Extremity Distraction

Choose Lower Extremity Distraction Category
Choose Lower Extremity Distraction Indication/Procedures for TSF / Ilizarov

Upper Extremity Trauma

Upper Extremity Trauma
IM-Nails
External Fixation
Plates and Screws

Upper Extremity Repair

Upper Extremity (Hand & Wrist)

Lower Extremity Repair

Lower Extremity (Foot & Ankle)

*** YOU MUST ORDER SAWBONES SEPERATELY. SEE CONVENTION SERVICES REQUEST FOR PRODUCT NUMBERS ***

Specimen Schedule

Ship In Date / Ship In Time:
:  
Specimen Pick Up Date and Time
:  
Tissue Specifications:
You may choose up to a maximum of 10.
You may choose up to a maximum of 10.
You may choose up to a maximum of 10.
You may choose up to a maximum of 10.
You may choose up to a maximum of 10.
You may choose up to a maximum of 10.
You may choose up to a maximum of 10.
You may choose up to a maximum of 10.

Listed below are the Convention Services page links to the request forms.

HCPs

**Provide names and information of all HCPs (Surgeons, Fellows) below.

Estimated number of surgeons attending

HCP Information - (S1)

Is S1 a
Educational Continuum
Resident: MD within a Residency Program
Fellow: MD within a Sports Medicine Fellowship
Competitive User: MD whom is a primary user of competitive products
Current User: MD whom utilizes S&N products for other joints and is looking to grow their product usage.
KOL: MD currently listed with S&N as a KOL
Competitive Consultant: MD currently a consultant with a competitive company
Resident
S1 - What type of S&N training or similar training have they had with this product? (Please check all that apply)
Have you utilized demo block or sawbones with your surgeon?*
Has surgeon been provided literature/study papers?*

HCP Information - (S2)

Is S2 a
Educational Continuum
Awareness: Non-user of technology (ancillary staff)
Beginner: To gain knowledge of products and procedures. Non-users of technology. (HCP, residents)
Intermediate: Minimal knowledge of products and procedures. (competitive users, new fellows)
Advanced: Knowledge of products and procedures. (current users)
Expert: Uses technology and procedures at an expert level (KOL’s)
Resident
S2 - What type of S&N training or similar training have they had with this product? (Please check all that apply)
Have you utilized demo block or sawbones with your surgeon?*
Has surgeon been provided literature/study papers?*

HCP Information - (S3)

Is S3 a
Educational Continuum
Awareness: Non-user of technology (ancillary staff)
Beginner: To gain knowledge of products and procedures. Non-users of technology. (HCP, residents)
Intermediate: Minimal knowledge of products and procedures. (competitive users, new fellows)
Advanced: Knowledge of products and procedures. (current users)
Expert: Uses technology and procedures at an expert level (KOL’s)
Resident
S3 - What type of S&N training or similar training have they had with this product? (Please check all that apply)
Have you utilized demo block or sawbones with your surgeon?*
Has surgeon been provided literature/study papers?*

HCP Information - (S4)

Is S4 a
Educational Continuum
Awareness: Non-user of technology (ancillary staff)
Beginner: To gain knowledge of products and procedures. Non-users of technology. (HCP, residents)
Intermediate: Minimal knowledge of products and procedures. (competitive users, new fellows)
Advanced: Knowledge of products and procedures. (current users)
Expert: Uses technology and procedures at an expert level (KOL’s)
Resident
S4 - What type of S&N training or similar training have they had with this product? (Please check all that apply)
Have you utilized demo block or sawbones with your surgeon?*
Has surgeon been provided literature/study papers?*

HCP Information - (S5)

Is S5 a
Educational Continuum
Awareness: Non-user of technology (ancillary staff)
Beginner: To gain knowledge of products and procedures. Non-users of technology. (HCP, residents)
Intermediate: Minimal knowledge of products and procedures. (competitive users, new fellows)
Advanced: Knowledge of products and procedures. (current users)
Expert: Uses technology and procedures at an expert level (KOL’s)
Resident
S5 - What type of S&N training or similar training have they had with this product? (Please check all that apply)
Have you utilized demo block or sawbones with your surgeon?*
Has surgeon been provided literature/study papers?*

HCP Information - (S6)

Is S6 a
Educational Continuum
Awareness: Non-user of technology (ancillary staff)
Beginner: To gain knowledge of products and procedures. Non-users of technology. (HCP, residents)
Intermediate: Minimal knowledge of products and procedures. (competitive users, new fellows)
Advanced: Knowledge of products and procedures. (current users)
Expert: Uses technology and procedures at an expert level (KOL’s)
Resident
S6 - What type of S&N training or similar training have they had with this product? (Please check all that apply)
Have you utilized demo block or sawbones with your surgeon?*
Has surgeon been provided literature/study papers?*

Facility Information

If you are requesting a lab at a Smith-Nephew facility, please register your information on VSP/CEV registration here: https://orthomeetings.com/vsponsight-registration/.


Address
I agree and acknowledge that there will be no photography within the lab.*

THE REP WILL BE NOTIFIED UPON CONFIRMATION OF THE FACILITY.

RETURN LABELS ARE INCLUDED IN YOUR WAREHOUSE SHIPMENT AND YOUR RETURN EQUIPMENT MUST BE RECEIVED BY THE WAREHOUSE WITHIN 3 BUSINESS DAYS FOLLOWING YOUR LAB

PLEASE FIND TRAUMA EXTREMITIES ORDERS UNDER CONVENTION SERVICES TAB ON THE MAIN PAGE OF ORTHOMEETINGS.COM

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