Carolinas Surgical Skills Center - Program Request Form

Our Organization

Company Name Lab, Course or Program Title Program Director (main contact) Phone Email Mailing Address - Line 1 Mailing Address - Line 2 City State ZIP Affiliated Faculty Names

Lab or Course Information

Requested Date(s) Requested Start Time Requested End Time Number of Attendees (include all staff, faculty and representatives) Number of Station(s) Procedure Summary (please provide details on all intended surgical practices and techniques) Specimen Type Specimen Quantity

Select how you would like your specimens ordered We prefer CSSC to order specimens on our behalf We prefer to order our own specimens

We will order from

Specimen Positioning

Select all that apply Extremity Holder Knee Board None Other Peg Board Trendelenburg

If other, please specify

Equipment

Select all that apply C-Arm (include number needed) Electro-cautery Large Bone Power Instruments (sawblades available only upon special request; additional fees apply) None Other Radiology Technician support (this must be requested ahead of time) Small Bone Power Instruments (sawblades available only upon special request; additional fees apply) Suction

If other, please specify If requesting a C-Arm, please specify the number needed If requesting saw blades, please specify type and quantity

Will equipment/instrumentation be shipped to Carolinas Surgical Skills Center? No Yes

Conference Space

Note: If arranging catering, conference space must be requested. Requested Date Requested Start Time Requested End Time A conference space is not needed

Presentation Needs

Select all that apply Microphone None Other Podium Projector Video Conferencing

If other, please specify

Catering

If arranging catering, conference space must also be requested. Breakfast - Meal Time Breakfast - Headcount Lunch - Meal Time Lunch - Headcount Dinner - Meal Time Dinner - Headcount Snacks - Meal Time Snacks - Headcount Catering is not needed

All PPE and general instrumentation will be provided by Carolinas Surgical Skills Center. Please include any special requests, questions, or comments in the space provided.

Questions or Comments

Terms and Conditions

The forms create using this module don not provide for the secure transmission or storage of data and Influence Health accepts no responsibility for any content entered into this form. I agree to the Terms and Conditions A representative from Carolinas Surgical Skills Center will respond to your request with an estimate to the email provided above within 3-5 business days. Please contact 704-304-0176 if you do not receive a follow-up call. We look forward to meeting you and hosting your event.

Program Request Form

Our Organization

Lab or Course Information

Specimen Positioning

Equipment

Conference Space

Presentation Needs

Catering

All PPE and general instrumentation will be provided by Carolinas Surgical Skills Center. Please include any special requests, questions, or comments in the space provided.

Terms and Conditions

About Atrium Health

Careers

For Employees

For Providers

For Employers

Carolinas Simulation Center

Program Request Form

Our Organization

Lab or Course Information

Specimen Positioning

Equipment

Conference Space

Presentation Needs

Catering

All PPE and general instrumentation will be provided by Carolinas Surgical Skills Center. Please include any special requests, questions, or comments in the space provided.

Terms and Conditions

About Atrium Health

Careers

For Employees

For Providers

For Employers