MP-100 - Mult-e Portal Set Order Form

If you would like to order the MP-100 sets, please contact Customer Service at (516) 277-9000 or customerservice@elliquence.com

MP-100 Mult-e Portal Order Form

Name

First

Last

Phone

Ship To

City

State/Province

Zip/Postal

Physician / Facility Name

Intended Procedure Intended Procedure

Date Needed By

Expected Return Date

Do You Need a Surgi-Max Ultra and Double Footswitch?

Yes

Do you currently have an Interlaminar or Stenosis Set?

Yes

Which set would you like with the Mult-e Portal Set?

Interlaminar

Stenosis

Trigger-Flex Quad (DTFQ-18) Amount Needed

Trigger-Flex Quad (DTFQM-24) Amount Needed

Trigger-Flex 31 (DTF-31) Amount Needed

Specific Instructions and/or Additional Equipment Needed

If you are human, leave this field blank.

MP-100 – Mult-e Portal Set Order Form