* = Required Field

COBLATION Surgeon Choice 1:*
Amin, Nirav MDFaucett, Scott MDFlanigan, David MDFriedman, Darren MDGambardella, Ralph MDHarris, Josh MDMcDonald, John MDMurphy, Lee MDPatel, Ronak MDPatterson, Mike MDRanawat, Anil MDWilcox, Jason MD

COBLATION Surgeon Choice 2:*
Amin, Nirav MDFaucett, Scott MDFlanigan, David MDFriedman, Darren MDGambardella, Ralph MDHarris, Josh MDMcDonald, John MDMurphy, Lee MDPatel, Ronak MDPatterson, Mike MDRanawat, Anil MDWilcox, Jason MD

Meeting Time:*

Sales Rep Name:*

Sales Rep Email:*

Sales Rep Cell Phone:*

DOS/TM or TM Name:*

Additional Comments:*

  I understand that sales rep is responsible for booking and paying for dinner.

  Faculty is in my region.

  Please confirm you have read below:
I understand that this date and surgeon request is NOT confirmed until I receive notice from Michelle Turner Medical Education Program Manager michelle.turner@smith-nephew.com

Please note: Smith & Nephew and its agents adhere to the AdvaMed Code of Ethics. Visit the AdvaMed website at www.advamed.org to review this policy. Attendance by federal, state or local US officials requires the authorization and approval of the employing agency.