Allograft Request Form MFG-F69[3]
(One form per Allograft Type) . MFG-F69[2] no longer in use
Name
*
Requester
E-mail
*
example@example.com
Date Requested
-
Day
-
Month
Year
Date
Tissue Disposition
R&D
Therapeutic
Allograft Infomation
One time Order
Recurring Order
Custom product type
*
Please select
Spinal
Orthopaedic
Soft Tissue
Foot & Ankle
Plastic
Dental
OMF
Other
Allograft released by date.
*
-
Day
-
Month
Year
6-8 week time frame
Allograft Tissue Description (Label):
*
For label
Attach images
*
Browse Files
Please attach any images of allograft with all dimensions.
Cancel
of
End User
Surgeon's name
Quantity needed
Details of case
Hospital, Date of Surgery, Procedure
Variances on all measurements
± 0.30mm
± 1.0mm
Length:
mm
Width:
mm
Height:
mm
Manufacturing Process
Yes
No
Centrifuged
1
2
SCF cleaned
3
4
Final Bioburden reduction method
Supercritical Fluid CO2
Gamma Irradiation
Primary Packaging
Tyvek (non-sterile)
Bag (sterile)
PET Tray
Delivery Device
Other (specify in notes)
Notes
Final Packaging
Inner label code
Final Packaging
Outer label code
Final Packaging
Box/Pouch code
End Product Storage
Frozen
Ambient (Freeze dried)
Submit
Stock Code
Customer Service Delegate to complete
Stock Code
To be created by Customer Service Mgr
Rebate Code
To be added by Customer Service Mgr
Email
example@example.com
Submit
Production Review
Allograft Request Approval
(initial & date)
Date
-
Month
-
Day
Year
Date
Submit
Quality Review
Quality Delegate to complete
Quality Review
Date
-
Month
-
Day
Year
Date
Email
example@example.com
Submit
Attach photos of finished product
Browse Files
Production Delegate
Cancel
of
Did surgeon approve?
Yes
No
Requires changes
Field Representative
Submit
Back
Next
One month Follow up
None
1-2
2-4
5+
New surgeons
5
6
7
8
Additional surgeon's using graft
Surgeon names
Monthly Forecast
No grafts per month
SUBMIT
Should be Empty: