Inventory Request Form Inventory Request Form Requested By * * Requested By * First First Last Last Email * * Phone * * Name of Person Covering the Case? * * Name of Person Covering the Case? * First First Last Last Name of the Distributor? * * Facility Name * * Surgery Date * * Surgeon * * Case Type : * Please Select OneACDFALIFCervical FixationEndo TLIFLLIFOpen Posterior FixationPerc TLIFPercutaneous Posterior FixationPLIFProduct DemoSI FixationTLIF New Shipment or Extension? * * New Shipment Extension Extension and New Shipment Add on Shipment for already scheduled case 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 *** Provide Set Numbers for each set you are requesting to extend * Shipping Address * Shipping Address * Shipping Address * Shipping Address * City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal ATTN: Arrival Date: * 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? Yes No 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? yes no 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 FlareHawk Selector FlareHawk 9/TiHawk9 TiHawk 11 FlareHawk7/TiHawk7 Open Instruments and Implants Endoscopic/ Percutaneous FlareHawk7/TiHawk7 Instruments and Implants FlareHawk9-PEEK 0 1 2 3 TiHawk9 (Sterile) 0 1 2 3 TiHawk9 (Non-Sterile) 0 1 2 3 TiHawk11 (Sterile) 0 1 2 3 FlareHawk/TiHawk 9 & 11 Instruments 0 1 2 3 FlareHawk7 Open (Instruments & Implants) 0 1 2 3 TiHawk7 Open (Instruments & Implants) 0 1 2 3 Open Disc Prep 0 1 2 3 MIS Disc Prep 0 1 2 3 Shaver & Distractor Tray 0 1 2 3 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 FlareHawk7 – Universal PERC/ENDO (MIS Instruments & Implants) 0 1 2 3 TiHawk7 – Universal PERC/ENDO (MIS Instruments & Implants) 0 1 2 3 Neuromonitoring Probe (Sterile, Used for PERC) 0 1 2 3 Wirebrush FHTPWB3 – 7.50 MM (Sterile packs of 2 each) 0 1 2 3 Wirebrush FHTPWB4 – 9.50 MM (Sterile packs of 2 each) 0 1 2 3 Is Fixation Needed? yes no Linesider Implants, Instruments Fixation Fixation Type Needed LINESIDER OPEN NON-MODULAR LINESIDER OPEN MODULAR LINESIDER CORTICAL MODULAR LINESIDER MIS NON-MODULAR LINESIDER OPEN NON-MODULAR If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made ONM General Instrument Tray 0 1 2 3 ONM LS Open Instruments Tray 0 1 2 3 ONM LS 5.5/6.0 Open Instruments Tray 0 1 2 3 ONM LS Open Implants Tray Cannulated Screws 0 1 2 3 ONM LS Open Implants Tray Solid Screws 0 1 2 3 ONM LS Reduction Screw Tray 0 1 2 3 ONM LS Iliac Tray 0 1 2 3 ONM LS 5.5-6.0 QC Reducer Tray 0 1 2 3 QC Reducers come standard in the 5.5/6.0 Open Instruments Tray qty 2 ONM Navigated Instruments for use with LineSider Spinal System 0 1 2 3 ONM LS Long Construct Tray Cannulated Screws 0 1 2 3 ONM LS Long Construct Tray Solid Screws 0 1 2 3 ONM LS Adjacent Segment Fixation Tray 0 1 2 3 LINESIDER OPEN MODULAR If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made OM General Instrument Tray 0 1 2 3 OM LS Open Instruments Tray 0 1 2 3 OM LS 5.5/6.0 Open Instruments Tray 0 1 2 3 OM LS Open Implants Tray- Modular Cannulated Shanks 0 1 2 3 OM LS Open Implants Tray- Modular Solid Shanks 0 1 2 3 OM LS Iliac Tray 0 1 2 3 OM LS 5.5-6.0 QC Reducer Tray 0 1 2 3 QC Reducers come standard in the 5.5/6.0 Open Instruments Tray qty 2 OM LS Long Construct Tray- Modular Cannulated Shanks 0 1 2 3 OM LS Long Construct Tray- Modular Solid Shanks 0 1 2 3 OM Navigated Instruments for use with LineSider Spinal System 0 1 2 3 LINESIDER CORTICAL MODULAR If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made CM General Instrument Tray 0 1 2 3 CM Cortical Instrument Tray 0 1 2 3 CM Cortical Implant Tray Cannulated Shanks 0 1 2 3 CM Cortical Implant Tray Solid Shanks 0 1 2 3 CM Accelus Midline Retractor Tray 0 1 2 3 CM Navigated Instruments for use with LineSider Spinal System 0 1 2 3 LINESIDER MIS NON-MODULAR If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made MIS General Instrument Tray 0 1 2 3 MIS LS MIS Instrument Tray 0 1 2 3 MIS LS MIS Implants 5.5-7.5 0 1 2 3 MIS LS MIS Implants 8.5-9.5 0 1 2 3 MIS Navigated Instruments for use with LineSider Spinal System 0 1 2 3 Is Biologics Needed ? Yes No Biologics If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made Bionest Cortical Fibers, Large-10CC 0 1 2 3 Bionest Cortical Fibers, Medium -5cc 0 1 2 3 Bionest Cortical Fibers, Small -2.5cc 0 1 2 3 Bionest DBM Putty, Large 0 1 2 3 Bionest DBM Putty, Medium 0 1 2 3 Bionest DBM Putty, Small 0 1 2 3 Is Accelcore Needed? Yes No Accelcore Accelcore Type needed Cervical Interbody (ACIF) Cervical Plates Standalone Interbody (ALIF) Cervical interbody (ACIF) If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made NanoHive Cervical Implants 0 1 2 3 NanoHive Cervical Instruments 0 1 2 3 Curiteva Sage Instruments 0 1 2 3 Curiteva Sage Peek Implants 0 1 2 3 Curiteva Sage Ti-Plasma Implants 0 1 2 3 Curiteva Sage Titanium Implants 0 1 2 3 Cervical Plates If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made 1-3 Level Standard Aptitude Plate Caddy 0 1 2 3 4 & 5 Special Levels Aptitude Plate Caddy (Special Request) 0 1 2 3 Standalone Interbody (ALIF) If set is NOT NEEDED LEAVE BLANK DONT USE 0 unless a mistake was made Instruments 0 1 2 3 Disc Prep 1&2 0 1 2 3 Implants Standard 8 x 15 Degree 0 1 2 3 Implants Special 22 Degree 0 1 2 3 Other-Write in notes Additional Notes / loose parts Visual Text ENTRY ID Captcha Submit If you are human, leave this field blank.
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