• Lab Request Form

    Lab Request Form

    Fill in as much information as feasible; if you need more information later, put TBD.
  • Please enter your name, phone, territory, regional manager:*
  • Date of proposed regional lab.*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Time for the lab (if unknown specify most likely morning, afternoon, evening, etc.)*
  • Please enter your full name, address of lab facility. *
  • Optional: shipment address if not the same as the lab.
  • Lab facility point of contact: phone or email. *
  • What is the focus of the regional lab? (foot/ankle, hip, knee, shoulder)*
  • What is the capacity of the facility in terms of stations?*
  • How many HCPs are expected to attend?*

  • JDM/Endo - SHIPPING COSTS TO BE COVERED BY RM

    The event will be delivered at 8 a.m. two days prior to the event, and collected up at 8 a.m. the following day. Please explain if you require other dates or times.
  • JDM
    Rows

  • Specimen

    Specimens are delivered to the lab the day before (thawed) and picked up the next day between 8am and 12pm. Please explain if you require other dates or times.
  • Specimen
    Rows
  • Do you need COVID-tested specimens at your facility? (It's worth noting that only hospitals demand this; other sorts of facilities are on a case-by-case basis.) For covid tested specimens, we are charged an additional fee.

  • Holders, Distractors, PPE

    Medsource drops off two days before the lab and picks up the next day. Please explain if you require other dates or times.
  • Holders, Distractors, PPE
    Rows

  • Power

  • How many power supplies (chuck, pin driver, key, battery, handle) are required?
  • Expired Allosource Allografts
    Rows
  • WISH LIST: Loaner Lab Sets Source locally whenever possible. We have a very limited supply.
    Rows
  • C-Arm, OR Bed
    Rows
  • Do you require disposables or implants from JPRepstock?
  • Do you require the major three disposables? - SPECIFY BURRS AND SHAVERS TYPES, AS WELL AS PUMP TUBING (INFLOW/OUTFLOW OR JUST INFLOW).
    Rows
  • Would you like to add any more information or questions?
  • Should be Empty:
Select theme: