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.
*
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Month
-
Day
Year
Date
If applicable, what is the name of the Consultant Proctor for this event?
*
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?
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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
How Many/Details
Video Towers
Camera
Light cord
Shaver Handpiece
Crossflow/Crossfire
Different delivery/pickup time? Specify here:
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
How Many
Clavicle to Fingertips (Shoulder Scope)
Hemi Pelvis to Mid Femur (Hip Scope)
Mid Femur to Mid tibia/Fibula (Knee Scope)
Mid Femur to Toe Tip (Knee Scope)
Mid Tibia/Fibula to Toes (Ankle)
Full Body without Cephalus
(for guardian use, needs RM approval)
Different delivery/pickup time? Specify here:
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.
Yes
No
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
How Many
Extremity holder (knee/shoulder/foot and ankle)
Hip Distractor
Guardian (limited supply, source from region first)
Adaptable Arm Positioner
PPE for how many people
Knife handles/blades
Ortho Instrumentation
Suction Macines
Cleaning Supplies
Floor mats
Any other specific lab needs:
Different delivery/pickup time? Specify here:
Drapes
Power
How many power supplies (chuck, pin driver, key, battery, handle) are required?
Expired Allosource Allografts
Rows
How Many
BTB
Allomend/GJ
Tibialis
Gracilis
Achilles(with or without bone block?)
Fascia Lata
Semi T
Quad Tendon (with or without patella?)
ProChondrix
WISH LIST: Loaner Lab Sets Source locally whenever possible. We have a very limited supply.
Rows
How Many
Monster ACL Set
Flexible Versitomic Reamers
ISI Instruments
Micro Fx
Sharpshooter Instruments
RR Instruments
Conquest Tray
Champion Shoulder Set
Iconix Instruments
Cobra
Pivot Hip Instrument Tray
Hip Arthroscopy Set
Scopes (specify type)
C-Arm, OR Bed
Rows
How Many
C-arm
Lead
OR Bed for use of Guardian
Do you require disposables or implants from JPRepstock?
Yes
No
Do you require the major three disposables? - SPECIFY BURRS AND SHAVERS TYPES, AS WELL AS PUMP TUBING (INFLOW/OUTFLOW OR JUST INFLOW).
Rows
Quantity
What kind?
Burrs
Shavers
Pump Tubing
Would you like to add any more information or questions?
Submit
Should be Empty: