TULA© Peer to Peer Call Request Form

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HCP Name*

HCP Facility Name*

HCP Facility City and State*

Name*

First Name

Last Name

Phone Number*

Email*

Regional Sales Manager*

Requested Faculty:*

Requested Date/Time - Option 1*

Requested Date/Time - Option 2*

Peer to Peer Call Objective:*

Has this HCP completed a Tula procedure or have a Tula procedure scheduled?*

Yes No

List all S+N employees to be included on call:*