Surgery New Product/Technology Request

Requestor *

Date *

Requestor's Phone Number *

Product/Technology *

Manufacturer Number *

Description *

Cost per Unit *

Vendor Name *

Vendor Contact Information *

How this new product/technology is beneficial? *

Anticipated annual usage of new item? (or state "one time use") *

What procedure type will the item will be used with? *

What item/technology will the new item replace? *

Vendor Name of Old Item *

Manufacturer Number of Old Item *

Description of Old Item *

Are there additional implementation costs or capital equipment requirements? *

Is the new Item FDA Approved? *

Yes
No

Is staff education required? *

Yes
No

Form Submission

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