The Lab Request form is designed to allow the sales representative to provide the required information for lab approval and execution for Recon / Real Intelligence.

**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)

Describe the business need for this event:*

Does this HCP have surgeries scheduled with the requested technology? *

If yes, list the date of surgery:*

Please list all S+N employees who will be attending the meeting and please provide a business justification for each person in attendance:*

Are Flights Required for S+N Employees?

Please list all HCP who will be attending this event and their business justification as to why they are attending:

Are Flights Required for HCP(s) to attend? *

If Yes, please list who needs flights. *

Has Facility Documented C-19 Changes to Operating Procedures? *

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.

If yes, are we able to comply with the facility standards? *

Identify step to ensure safe environment for S+N employees & customers*

Temperature prior to facility entry C-19 questionnaire prior to facility entry Social distancing mandates Facility capacity limitations PPE Requirements Food safety protocols

Will food be served?

If yes,

I acknowledge no food will be served during labs which are less than four (4) hours in length I acknowledge all meals will be served in individualized packages, inclusive of beverages

RECON and REAL INTELLIGENCE Labs

If this is taking place at Austin or Plymouth, continue filling out this form.

Click Here to Fill Out The Memphis OnSite Request.

Click Here to Fill Out The Phoenix OnSite Request.

Click Here to Fill Out The Andover OnSite Request.

Is this a KAISER lab? *

Yes No

Is this a Austin, TX Onsite Lab Facility?

Yes No

Is this a Cordova, TN Onsite Lab Facility?

Yes No

Is this a Andover, TN Onsite Lab Facility?

Yes No

Is this a Plymouth, MN Onsite Lab Facility?

Yes No

Is this a Phoenix, AZ Onsite Lab Facility?

Yes No

Do your have approval for this lab from your AVP? Please do not continue to complete this form until you have approval. We will provide to your AVP the correct cost/estimate.*

Yes

I understand that the costs of this lab will be charged back to my AVP's cost center without approval. *

Yes

Is this lab in conjunction with a Hospital VSP? *

Yes No

If yes, please contact either Ashley Archibald or Nancy Cranford regarding Hospital Visiting Surgeon Program (HVSP).

Ashley Archibald
Email: Ashley.Archibald@smith-nephew.com
Phone: 978-289-8250

What Type of Lab? (Choose all that apply)

RECON REAL INTELLIGENCE

Who is your AVP? *

Who is your CES?*

Who is your RTD?*

Smith and Nephew Representative / Requestor*

First Name

Last Name

Smith and Nephew Representative Phone Number

Smith and Nephew Representative Phone Number*

Smith and Nephew Representative Email*

Name of DOS*

First Name

Last Name

Is a Smith and Nephew Faculty Required? *

Please list the name of the consultant that you would like to use. We will attempt to use your suggestion, however final choice will be chosen by clinic specialist. *

Lab Setup Date*

:

Start Date of Meeting - Lab*

:

End Date of Meeting - Lab*

:

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/.

Name of Lab Facility or Hotel*

Name of Contact Person for Lab Facility or Hotel*

Address of Lab Facility or Hotel*

Address Line 1

Address Line 2

City

State

ZIP Code

Lab Facility or Hotel Phone Number

Lab Facility or Hotel Phone Number*

Lab Facility or Hotel Email*

Please list the exact S&N Products you will be covering during your lab. Please be product specific. We will be tracking the products usage and training. *

Are you training on VISIONAIRE? *

Yes No

VISIONAIRE Confirmation*

Are you training on any REAL INTELLIGENCE Products?*

Yes No

REAL INTELLIGENCE Unit Confirmation*

REAL INTELLIGENCE Unit Selection*

I will be securing instrumentation from*

Locally / Own Warehouse Loaner Banks Convention Services

Number of Surgeons Attending*

Please list all target surgeons information that includes Target Surgeon Name, Type of Surgeon (Attending, Fellow, Resident), Hospital Account Name.*

Number of Lab Stations*

Number of Requested Specimens*

*Please provide any additional, specific information that could be helpful in the proper execution of this lab

I understand that Sales is responsible for securing all S&N Instrumentation. *

Yes I understand.

I understand that all Food, Beverage, and Parking expenses is the responsibility of the Sales team and must be invoiced separately.*

Yes I understand.

Due to the large demand for S&N instrumentation, please initially attempt to secure instruments locally.
If you are unable to secure them, please request through loaners.

**Your last option should be Convention Services, as they are covering both national and international labs. If you have to request through Convention Services please allow extra time, as advanced notice will be required for all requests.

I understand that securing S&N instruments should be followed in the order listed above.*

I understand.

Recon / Real Intelligence and C-19 Lab Request Form Addendum C-19 Lab Request Form Addendum

RECON and REAL INTELLIGENCE Labs

If this is taking place at Austin or Plymouth, continue filling out this form.