For Patients
Contact Us
(516) 277-9000
Open Menu
HEALTHCARE PROFESSIONALS
Medical Technology
RADIOFREQUENCY
Surgi-Max® Family
Surg-e Pak™
MINIMALLY INVASIVE SPINE
Disc-FX® System
Endoscopic Spine Systems
Surgi-Max Drill
Trigger-Flex® Family
Bi-Tip™
NEUROSURGERY
Micro Bipolar
Bipolar Forceps
Surgi-Max® Radiowave Accessories
Training and Workshops
U.S.A.
EMEA
South America
Clinical Education & Resources
Coding and Reimbursement
Clinical Literature
Visual Applications
Upcoming elliquence Webinars
PATIENTS
Disc-FX Overview
Understanding Endoscopic Spine Surgery
NEWS & EVENTS
News
Featured Stories
Testimonials From Medical Professionals
ABOUT
Overview
Quality Management System
Career Opportunities at elliquence
Warranty Registration
Customer Survey
Test Sign Up
Authorized and Non-Authorized Products
Contact
HEALTHCARE PROFESSIONALS
Medical Technology
RADIOFREQUENCY
Surgi-Max® Family
Surg-e Pak™
MINIMALLY INVASIVE SPINE
Disc-FX® System
Endoscopic Spine Systems
Surgi-Max Drill
Trigger-Flex® Family
Bi-Tip™
NEUROSURGERY
Micro Bipolar
Bipolar Forceps
Surgi-Max® Radiowave Accessories
Training and Workshops
U.S.A.
EMEA
South America
Clinical Education & Resources
Coding and Reimbursement
Clinical Literature
Visual Applications
Upcoming elliquence Webinars
PATIENTS
Disc-FX Overview
Understanding Endoscopic Spine Surgery
NEWS & EVENTS
News
Featured Stories
Testimonials From Medical Professionals
ABOUT
Overview
Quality Management System
Career Opportunities at elliquence
Warranty Registration
Customer Survey
Test Sign Up
Authorized and Non-Authorized Products
Contact
IL-200 – Interlaminar Set Order Form
All Orders Received after 3:30 pm EST are not guaranteed to ship the same day.
elliquence will cover ground shipping costs. The rep or facility is responsible for any shipping cost above the standard ground cost.
IL-200 - Interlaminar Set Order Form
Name
*
Name
First
First
Last
Last
Phone
*
Email
*
Ship To
*
Ship To
Ship To
Ship To
City
City
State/Province
Alabama
Alaska
Arkansas
Arizona
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State/Province
Zip/Postal
Zip/Postal
Physicians / Facility Name
*
Intended Procedure
*
Endoscopic Transforaminal Approach
Endoscopic Interlaminar Approach
Endoscopic Facet Denervation
Endoscopically Assisted Fusion
Endoscopic Stenosis Decompression
Endoscopic Posterior Cervical Decompression
Date Needed By
*
Expected Return Date
*
How many endoscopes will you need with this order?
*
1
2
Will you need a Surgi-Max Ultra and Double Footswitch ?
*
Yes (IEC6-SU170 and BF-FSCB)
No
Trigger-Flex 31 (DTF-31)
*
Trigger-Flex Quad Pro (DTFQM-31)
*
Recommended - 16g Spine Needle (DFX-N6/1) Amount Needed
*
18g Spine Needle (DFX-N8/1) Amount Needed
*
Specific Instructions and/or Additional Equipment Needed
If you are human, leave this field blank.
Next
Start Over
Translate »