Organization *
Contact Name *
Contact Number *
Contact email
Requested Time (select all that apply)
Morning (Until Noon)Afternoon (12-4pm)Evening (4 or later)TBD
Course Topic:
Number of Participants
Type of Participants (check all that apply)
Physicians/SurgeonsFellowsResidents RepsR&DOther
Numbers of Stations Required
Specimen Sourcing and Management by PAB
—Please choose an option—Yes, Please Source SpecimensNo, we will have specimens deliveredOtherTBD
Tissue Information
*Specimen type/description, Quantity, Rule-out parameters, Scans needed.
We will need general instrumentation provided by PAB YesNo
Extremity Holder:
Bovie/Electrocautery:
Suction:
Reciprocating Saw:
Sagittal Saw:
Drill:
Other Equipment:
Full C-Arm Xray Technologists requested?:
Mini C-Arm:
Didactic Room/Meeting Space Reservation * YesNo
Catering * Yes, (our coordinator will be in contact regarding catering details)No catering needed
Comment/Notes (optional)
