MEDINC - JOURNAL CLUB request form
Todays Date
*
/
Month
/
Day
Year
Date Picker Icon
Sales Rep Responsible for Journal Club
*
First Name
Last Name
Sales Rep Submitting Request
*
First Name
Last Name
Director Approval?
*
Mike Pawelek
Kevin Price
Ryan Hubele
Danny Hannafin
Shane McDermott
Tim Wascher
Matt Schirmer
Expected Attendees
*
Teams
Leading Surgeon Name
*
Affiliated Organization
*
# of HCP attending
*
# of MedInc of Texas attending
*
EVENT INFORMATION
Journal Club Date
*
-
Month
-
Day
Year
Date Picker Icon
Location of Event
*
Houston Office
Offsite Location
If location is offsite what is the address of location?
*
Start Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
End Time
*
1
2
3
4
5
6
7
8
9
10
11
12
:
Hour
00
10
20
30
40
50
Minutes
AM
PM
AM/PM Option
What qualified this group for Journal Club?
*
AGENDA
What articles are to be discussed?
*
***It is your responsibility to get the articles out to MedInc representatives if you receive them after submitting this form.
What Equipment will you need for display from Lab Services?
*
V300
V400
V600
Graftboard Set
ACL Toolbox
PCL Set
Retroconstruction
Flexible Reamer Guide
Hand Instruments
Collateral Lig.
Meniscal Repair Set w/ Scorpion
iBalance HTO
iBalance Uni Knee
Master Hip Instruments
Extended Length Hip Scopes
Standard Hip Scope Set
Hip Accessory Set (Scorpions & Trim-It)
Master Shoulder
UCL Set
AC Joint Recon
Clavicle Fx
Shld Retractor
Univers II Sets
Apex Sets
Revers Sets
Hum. Suture Plate
Shoulder Fx Stem
Ankle Fx
4.5/6.7 Screws
Bio-Tenodesis
CFS (3 Tray)
PARS Jig
Internal Brace Set
SLAM Repair
5th Metatarsal
CPR Set
Distal Radius Fx
Headless FT
Quick Fix Cann.
Ankle Fusion
No Sets Needed
Elbow/Ankle Arthroscopy
Plantar Lapidus
If more than one each is needed please list below. If any other sets are needed please list below.
Request Specialty Manager attend
*
Art Rios
Brad Dierks
Brandon Hamilton
Charlie Benson
Kati Schantz, PA-C
Kevin Price
Mike Pawelek
Scott Cowan
Justin Schulte
Eric White
Rachel Stewart
None
What Biologics Topics will you cover in addition to your event agenda?
ACP/BMAC
AFlex
AlloSync
Amnion
Arthrocell
Biocartilage
BioUni
Cartiform
Fresh Cores
Jumpstart
Quickset
Tendons/Grafts
What literature needs to be available? Be specific.
*
If you need any samples ordered from Arthrex Lab Services, please list below:
Meal?
*
I acknowledge that...
*
I will turn in a typed list of the attendees for the journal club after the event has concluded in addition to the HCP sign in sheet.
Submit
Should be Empty: