MEDCURE SURGICAL TRAINING CENTER COURSE REQUEST Formpage1 of 4

MEDCURE SURGICAL TRAINING CENTER COURSE REQUEST FORMPage1 of 4

All lines are Mandatory. If a line does not apply please fill in N/A or -- . Do not leave blanks. Forms not filled out completely and correctly could delay course scheduling.

COMPANY INFORMATION

Company Name:Contact Person:

Company Address:

City:State:Zip:Office Phone:

Mobile:Fax:Email:

Today’s Date:Setup Date:Setup Time: Setup date subject to availability

Day 1 Date:Start Time:End Time:Day 2 Date:Start Time:End Time:

FACILITY INFORMATION: Henderson, NV:Cumberland, RI:Portland, OR:

Conference Room/Auditorium: / Yes No / Audio/Video Recording: / Yes No
Projection Screen: / Yes No / Video Conferencing: / Yes No
Microphones for lab interaction: / Yes No / Catering Area: / Yes No

COURSE INFORMATION(If available, please include a copy of your course brochure oragenda):

Name of Course:

# of Participants:# of Lab Stations:

Procedure Summary:

SPECIMEN INFORMATION

Specimen TypeQty

Specimen Specifications:

Check “yes” if specimens should be imaged before the course. Check “no” if they should not.

X-ray: Yes No CT Scan: Yes No Dexa Scan: Yes No

INSTRUMENTATION SERVICES

Suture / Power & Fluoro
Type/Material: / # Small Power Drills: / # Large Power Drills:
Needle Type: / # Small Power Saws: / # Large Power Saws:
Size: / # C-arms: / # Lead Protection:
Qty:

General Instrumentation Package: Yes No

See page 3 for General Instrumentation list and space to add additional instrumentation requests.

CATERING

Number / Time / Hot / Cold
Breakfast
Snack
Lunch
Snack
Dinner

HOTEL/TRANSPORTATION

Transportation (number of people):Lodging (number of rooms):

Participants’ Hotel (if known):

Address:

City:State: Zip:

BILLING INFORMATION

Billing Contact:Contact Phone:

Billing Address:

City:State:Zip:

Purchase Order # (if applicable):

TERMS & CONDITIONS

By signing and/or entering your name below you are agreeing to abide by the MedCure, Inc. Application & Agreement for Anatomical Specimens for Research & Education.

By signing you also agree:

To treat the donated specimens in a dignified and respectful manner at all times.
Anatomical specimens shall only be used and handled by trained and technically qualified individuals.
That special care and strict adherence to any and all governmental regulations, safe laboratory practices, and universal precautions shall be maintained when handling anatomical specimens.

Signature / Print Name / Date

Request forms may be faxed to 503-542-2249 or emailed to

If you have any questions call Lisa Martin at 503-764-9919.

GENERAL INSTRUMENTATION

For items with multiple sizes, please circle your preferred size.

Cutting & Dissecting / Qty / Grasping & Holding / Qty / Retracting & Exposing / Qty
Lister Bandage Scissors / Allis Tissue Forceps / Army Navy Retractor
Mayo Scissors- Curved / Backhaus Towel Clamps / Deaver Retractor
Mayo Scissors- Straight / Debakey Tissue Forceps / Gelpi Retractor
Metzenbaum- Straight / Ferris –Smith Forceps / Bennet Retractor
Currette / Forester Sponger Forcep / Crile Retractor
Osteotome (½”) / Hudson Tissue Forceps / Fukuda Retractor
Ronguer / Kelly Forceps- Curved / Hohman Retractor
Elevating & Exposing / Kocher Forceps / Ribbon Retractor
Bone Hooks / Lorna Towel Clamps / Richardson Retractor
Chandler Elevator (8, 9¼”) / Mixter Forceps / Senn Retractor
Cobb Elevator (¾, 3/8, 1”) / Needle Drivers / Speculum (Weighted)
Freer Elevator / Roch-Och Forceps / Tissue Rake
Other / Roch-Pean Forceps / Weitlaner Retractor
Mallets (Small, Large) / Schnidt Forceps
Scalpel Blade (#10, #11) / Tissue Forceps

General Surgical Supplies include: Gauze (4x4), Lubricant, Surgical markers, Syringes, Tape, Suction w/ Yankauer Tips, Scalpel Handles (#3, 3L).

ADDITIONAL INSTRUMENTATION

We are happy to provide you with instrumentation that falls outside of our standard set listed above. Please list any additional items you require, including quantity and size. We will contact you regarding details and pricing.

Qty / Item / Notes (size, type, etc.)

ADDITIONAL ARTHROSCOPIC COMPONENTS

Item / Qty / Size/Type / Item / Qty / Size/Type / Item / Qty / Size/Type
Monitor / Shaver / Insulflator
Light source / Saline Pump / Scopes
Camera box / RF Generator / Probe

18111 NE Sandy Blvd, Portland, OR 97230 Phone 503.764.9919 Fax 503.542.2249

Form: 174D – 08/12