Demo and Cadaver Equipment Request Form – INR "*" indicates required fields Step 1 of 3 33% Meeting/Event InformationEmail* Assigned Meeting Planner / Tradeshows Lead*System Type*MarketingKencoEvent Type* Surgeon Demo Cadaver Lab Tradeshow/Meeting Equipment Type* EGPS EHUB E3D PSS Procedure Type* Pedicle Screws Single Position Lateral Prone Lateral TLIF SI Fusion Posterior Cervical Cranial Event Name/Title*Event Location*Requestor NameShipping InstructionsArrival Date* MM slash DD slash YYYY Arrival Time*Departure Date* MM slash DD slash YYYY Departure Time*Meeting Date* MM slash DD slash YYYY Consign Sets To*Ship To/AttentionStreet Address*City*State*Zip*Country*Phone #*If you don’t know, please find out and come back to this form.Does the location have a full loading dock?*YesNoCan the crate/s stay onsite?*YesNo Set NumberDescriptionQty9262.9004EDDuraPro Oscillating System Education Set9262.9004ED – DuraPro Oscillating System Education SetPlease enter a number greater than or equal to 1.9261.9001EDVerzera Drill System Instrument Education Set9261.9001ED – Verzera Drill System Instrument Education SetPlease enter a number greater than or equal to 1.9261.9002EDVerzera Drill System Capital Equipment Education Set9261.9002ED – Verzera Drill System Capital Equipment Education SetPlease enter a number greater than or equal to 1.6143.2584S or 6143.2582SHigh Speed Drill Bit, 4.5mm, GPS or High Speed Drill Bit, 3.5mm, GPS6143.2584S or 6143.2582S – High Speed Drill Bit, 4.5mm, GPS or High Speed Drill Bit, 3.5mm, GPSPlease enter a number greater than or equal to 1.6261.5457SVerzera 4.5mm Round Fluted Bur, 22.5cm, GPS6261.5457S – Verzera 4.5mm Round Fluted Bur, 22.5cm, GPSPlease enter a number greater than or equal to 1.6261.6304SVerzera 3.0mm Match Head Bur, 11cm, GPS6261.6304S – Verzera 3.0mm Match Head Bur, 11cm, GPSPlease enter a number greater than or equal to 1.6143.2001Excelsius Arm Drape, 10CT6143.2001 – Excelsius Arm Drape, 10CTPlease enter a number greater than or equal to 1.6143.2003Excelsius Monitor Drape, 20CT6143.2003 – Excelsius Monitor Drape, 20CTPlease enter a number greater than or equal to 1.6143.2590S or 6143.2591SPassive Markers, 5 Markers x 12 Trays (60 CT) or Passive Markers, 15 Markers x 2 Trays (30 CT)6143.2590S or 6143.2591S – Passive Markers, 5 Markers x 12 Trays (60 CT) or Passive Markers, 15 Markers x 2 Trays (30 CT)Please enter a number greater than or equal to 1.NASurgiSTUD (bioskills labs only)NA – SurgiSTUD (bioskills labs only)Please enter a number greater than or equal to 1.675.405SBayonetted Annulotomy Knife675.405S – Bayonetted Annulotomy KnifePlease enter a number greater than or equal to 1.675.399SK-Wires675.399S – K-WiresPlease enter a number greater than or equal to 1.698.605SMIS Illumination System698.605S – MIS Illumination SystemPlease enter a number greater than or equal to 1.6143.1828S Navigated Biopsy Needle, GPS6143.1828S – Navigated Biopsy Needle, GPSPlease enter a number greater than or equal to 1. Notes/Comments
