Inventory Request Form

Inventory Request Form
Requested By *
Requested By *
First
Last
Name of Person Covering the Case? *
Name of Person Covering the Case? *
First
Last
New Shipment or Extension? *
Select “New Shipment” if ANY SHIPMENT is associated with this request. OR Select “Extension” to extend sets you already have for another case. **Note: Distribution will not be notified to ship for an extension ***
Shipping Address *
Shipping Address *
City
State/Province
Zip/Postal
This is the date the item is scheduled to Arrive. Items will arrive on this Date by 10:30 am to business addresses OR by noon to most residences. Default shipping: – 2 business days prior to scheduled surgery – via FedEx P1 – arrival the business day before surgery. Early shipping may require additional justification. – Add any additional shipping information in additional notes section below (ex. 1st am delivery)
Is Saturday Delivery Required?
Most hospitals do not receive packages on Saturday. Saturday deliveries are recommended to ship to residence or Fedex Hold for Pick Up.
Is Flarehawk needed?
Includes FH Implants, FH Instruments and Disc Prep

Flarehawk Loaners Needed

Requests for more than one set per case may require additional justification . If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made

Endoscopic Fusion / Percutaneous Fusion Loaners Needed

Requests for more than one set per case may require additional justification . If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made
Is Fixation Needed?
Linesider Implants, Instruments

Fixation

Fixation Type Needed

LINESIDER OPEN NON-MODULAR

If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made
QC Reducers come standard in the 5.5/6.0 Open Instruments Tray qty 2

LINESIDER OPEN MODULAR

If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made
QC Reducers come standard in the 5.5/6.0 Open Instruments Tray qty 2

LINESIDER CORTICAL MODULAR

If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made

LINESIDER MIS NON-MODULAR

If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made
Is Biologics Needed ?

Biologics

If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made
Is Accelcore Needed?

Accelcore

Accelcore Type needed

Cervical interbody (ACIF)

If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made

Cervical Plates

If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made

Standalone Interbody (ALIF)

If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made