Surgery Order Form – BioPro University

Your Name *

Email Address *

Facility Name *

Surgeon name

Date of Surgery

Ship To Name:

Is this the first time BioPro has shipped to this address?

Street Address

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Does the surgery require more than one implant or are there multiple surgeries scheduled? (i.e., bi-laterals or multiple fixations for fusion)YesNoUnknown

Important Note:

If a product is sterile, (2) of each will be sent per surgery. (1) Instrument tray will be sent per surgery. Please specify if different quantities are required.

Hand & Wrist – Check all that apply.

Modular Thumb Implant Standard + 4.0-6.5mm BurrsModular Thumb Implant Titanium + 4.0-6.5mm BurrsModular Thumb Implant Revision Stem + 4.0-6.5mm BurrsOsteotec Silicone Finger ImplantClover Staple 3-Leg + 1.5mm DrillClover Staple 4-Leg + 1.5mm Drill

Sterile Instruments (Check all that apply)Please provide PO # as these items are not to be consigned.

Other (Product Not Listed)Please be specific (Vivosorb 2x3cm, DBM Bone Putty 2.5cc)