Equipment Request Form

Request a WFNS Basic Set of NS Microscope and/or Bipolar Coagulator

Full name of the person requesting the set(s) and/or
Microscope (please precise whether you need Set or
Microscope or both): *
Full name of Hospital where Set/Microscope is to be
delivered to and used: *
Department: *
Street: *
City: *
Tel. Fax : *
Postal code: *
Country: *
Email: *
Full name of the contact person of the hospital: *
Number of neurosurgeons in your country: *
Number of Neurosurgical Centers in your country: *
Population in your country: *
Number of neurosurgeons and/or surgeons in the hospital: *
Number of neurosurgical (or surgical) beds in the Hospital: *
How many surgeons will be using or having access to the
instruments: *
Number and type of surgical procedures performed during
the last year: *
Cooperation (or not) with other specialties, e.g. intensivists,
radiologist, neurologists, pediatricians: *
Are you a Member or not of the neurosurgical or surgical
society in your country:		 (yes/no)
Name of that Society:
Do you already have some surgical or neurosurgical
instruments at your disposal, if so, which kind:
Do you have a CT scanner: (yes/no)
Do you already have a Surgical Microscope at your disposal: (yes/no)
Do you have an Ultrasonic Aspiration at your disposal: (yes/no)
What are your main reasons for requesting the WFNS
Basic Set of Instruments and/or Microscope: *
Do you already have a sponsor: (yes/no)
Full name of the sponsor:
Street:
City:
Tel. Fax:
Postal code:
Country:
Email:
Information on how to declare the shipment/which shipping
documents are necessary:

N.B: In the case of approval of your request for a Set/Microscope, the donator making the bank transfer should indicate WFNS Basic Set of Neurosurgical Instruments - Ref: 8050264 or Microscope - Ref CZ-1206-904 in order that your payment can be easily recognized.