ST-400 - Stenosis Set Order Form

Name

First

Last

Phone

Ship To

City

State/Province

Zip/Postal

Country

Physician / Facility Name

Dropdown

Date Needed By

Expected Return Date

How many endoscopes will you need with this order?

Do you need a Surgi-Max Ultra with Double Footswitch?

Yes

Trigger-Flex Quad (DTFQ-31) Amount Needed

Trigger-Flex Quad Pro (DTFQM-31) Amount Needed

Trigger-Flex 31 (DTF-31) Amount Needed

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.

ST-400 – Stenosis Set Order Form