REQUEST FOR LOAN OF SURGICAL EQUIPMENT

REFERENCE NUMBER:

DATE OF REQUEST

REQUESTED BY

DATE OF OPERATION

ALL KIT WILL HAVE A DELIVERY REQUEST OF 48 HOURS PRIOR TO SURGERY UNLESS STATED/REQUESTED OTHERWISE

THEATRE

NAME OF SURGEON

INSTRUMENTS/IMPLANTS REQUIRED

FOR ALLOGRATH LONG/SHORT?

PROCEDURE NAME

PROPOSED SUPPLIER

COMPANY REP REQUIRED?

REP DETAILS IF KNOWN - NAME, PHONE NUMBER AND EMAIL ADDRESS

IS THERE A SUITABLE ALTERNATIVE KIT ON THE SHELF Y/N

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FOR ALL URGENT REQUESTS PLEASE DIAL 19600 AND ASK FOR EITHER STAFF MEMBER THROUGH VOCERA