Endoscopy Medical Education Form
Facility Name
Full Facility/Lab Name
Delivery Date/Time
*
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Delivery Day of Week
Pick-up Date/Time
*
/
Month
/
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Pick-up Day of Week
Delivery Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Requested Equipment
*
Please enter requested equipment. For Guardian or Dart (Robot) equipment, please use field below.
Please explain business opportunity/need
Required for approval
Stryker Employee Name
*
First Name
Last Name
Stryker Employee Email
*
example@example.com
Stryker Employee Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Stryker Manager Name
*
First Name
Last Name
Stryker Manager Email
*
example@example.com
Facility On-site Contact Name
*
First Name
Last Name
Facility On-Site Contact Email
*
example@example.com
Facility On-Site Contact Phone #
*
Please enter a valid phone number.
Format: (000) 000-0000.
Delivery Instructions
Special Delivery Instructions
Cost Center for Shipping Costs
*
Stryker Division Old
Stryker Business Unit
*
Please Select
Endo and Comm
ENT
Foot/Ankle
Instruments
Joint Replacement
Sports Medicine
Other
Workshop Surgical Services
*
Please Select
Breast
General Laparoscopic
Gyn
ENT
Joint Replacement
Sports
Thoracic
Urology
Other
Stryker Event
*
Yes
No
External Grant
*
Yes
No
How many estimated HCP have been invited to the event?
*
Region
*
Pick-up date/time must be AFTER the delivery date/time.
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