COE Application Form

Thank you for your interest in attending our Radial to Peripheral Education Program. Please fill out the following application for consideration into the program.
Full Name: *

First Name Last Name
Facility Name: *
Facility Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
NPI # *
Specialty *
Our Program offers the opportunity for a physician and ONE additional allied health (nurse/tech) team member to attend this program. Please list additional team member and contact information
Additional Team Member Name

First Name Last Name
Additional Team Member Email
example@example.com
Select your preferred program: *

Dr. Craig Walker, August 23-24, 2022, Houma Lousiana Dr. Craig Walker, October 11-12, 2022, Houma Lousiana
Note: if your facility is selected, we will make every effort to match with your desired choice.
If your preferred date is not available would the alternate date be an option? *
Where did you complete your radial training? *
Please rate your CLINICAL RADIAL EXPERIENCE *
Please rate your CLINICAL PERIPHERAL EXPERIENCE (Specifically Iliac & SFA) *
Please rate your RADIAL TO PERIPHERAL CASE experience: *
Do you currently have Radial to Peripheral product(s) in your facility? *
Do you currently have support from your facility to adopt and implement a radial to peripheral program? *
Please select your EXPOSURE to Radial to Peripheral procedures.

I have never performed a Radial to Peripheral case and haven't seen any cases. I have never performed a Radial to Peripheral case but I've watched some cases online. I have never performed a Radial to Peripheral case but I've attended some in-person cases. I have tried a few Radial to Peripheral cases but haven't felt comfortable enough yet to incorporate them consistently into my workflow. My practice consistently performs Radial to Peripheral cases but would like to optimize our techniques or learn new troubleshooting methods. Other
What areas of interest do you have in Radial to Peripheral? Please select ALL that apply: *

How to start a program New Techniques Basic cases Advanced / complex cases Workflow Room Set Up Patient Flow Troubleshooting Spasm Protocol Nurse/Tech Training Other
Thank You for your interest in our Clinical Education and Training Programs.
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