Disc-FX and Disc-FX Mini Order Form

Disc-FX Order Form

Name

First

Last

Phone

Ship To Address

City

State/Province

Zip/Postal

Date Needed By

Physician / Facility Name

Disc-FX Kits Needed (DFX)

Grasping Forceps Needed (DFX-G)

Spine Needles Needed (DFX-N6/1)

2.7 Scope Needed

Yes

Will you need a Retractor, Dilator and Light Cables?

Yes

Disc-FX Mini Kits Needed (DFXM)

Short Grasping Forceps Needed (DFX-GS)

Access Needles Needed (N6/D4/1)

Special Instructions

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