*Available dates will be shaded a dark grey.

*Webinars are shaded in orange.

* = Required Field

NOVOSTITCH Surgeon Choice 1:*
Bankston MD, Larry (Chip)Brooks MD, KennethChang MD, SpencerColyvas MD, NicholasFaucett MD, ScottFlanigan MD, DavidGomoll MD, AndreasKurzweil MD, PeterLarson MD, JamesLiu MD, JosephMcIntyre MD, LouisMurphy MD, Randall LeeNepple MD, JeffreyPadley DO, GrantPatel MD, RonakRanawat MD, AnilRichardson MD, LarsSaliman MD, JustinSherman MD, SethStrauss MD, EricStrickland MD, SabrinaVan Thiel MD, GeoffreyVaughn MD, ZacharyWhite MD, Jared

NOVOSTITCH Surgeon Choice 2:*
Bankston MD, Larry (Chip)Brooks MD, KennethChang MD, SpencerColyvas MD, NicholasFaucett MD, ScottFlanigan MD, DavidGomoll MD, AndreasKurzweil MD, PeterLarson MD, JamesLiu MD, JosephMcIntyre MD, LouisMurphy MD, Randall LeeNepple MD, JeffreyPadley DO, GrantPatel MD, RonakRanawat MD, AnilRichardson MD, LarsSaliman MD, JustinSherman MD, SethStrauss MD, EricStrickland MD, SabrinaVan Thiel MD, GeoffreyVaughn MD, ZacharyWhite MD, Jared

NOVOSTITCH Surgeon Choice 3:
(You must have 5 confirmed surgeon attendees before we request the following surgeons):*
Bankston MD, Larry (Chip)Brooks MD, KennethChang MD, SpencerColyvas MD, NicholasFaucett MD, ScottFlanigan MD, DavidGomoll MD, AndreasKurzweil MD, PeterLarson MD, JamesLiu MD, JosephMcIntyre MD, LouisMurphy MD, Randall LeeNepple MD, JeffreyPadley DO, GrantPatel MD, RonakRanawat MD, AnilRichardson MD, LarsSaliman MD, JustinSherman MD, SethStrauss MD, EricStrickland MD, SabrinaVan Thiel MD, GeoffreyVaughn MD, ZacharyWhite MD, Jared

Meeting Time:*

Sales Rep Name:*

Sales Rep Email:*

Sales Rep Cell Phone:*

DOS/TM or TM Name:*

Additional Comments:*

  Sales Rep or MDM’s will create the invitation for the Dinner Symposia.

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

  Please confirm you have read below:
I understand that this date and surgeon request is NOT confirmed until I receive notice from Ashley Archibald Medical Education Program Manager Ashley.Archibald@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.