Equipment Request Form

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

Full name of the person requesting the neurosurgical equipment:
     
Equipment requested    
WFNS Cranial Set (Ref: 20008380 / XG216)
WFNS Spinal Set (Ref: 20008380 / XG217)
WFNS Bipolar Coagulation Set (Ref: 20008380 / XG601)
WFNS High-Speed Drill Set (Ref: 20008380 / XG219)
WFNS Microscope (Ref: CZ-1206-904)
     
Information about where the neurosurgical equipment would be delivered to and used
Full name of Hospital  
Full name of contact person  
Department:  
Street:  
City and Country:  
Postal Code:  
Email address:  
Tel. No:  
Fax No:  
     
About your country    
Number of neurosurgeons  
Number of neurosurgical centres, if any:  
Population  
 
Regarding the Hospital    
Number of Neurosurgeons (*Please precise exact number of each):
Number of Surgeons
Number of neurosurgical (or surgical) beds  
Number of surgeons using or having access to the instruments:  
Number and type of surgical procedures performed during the last year, if any:  
Cooperation (or not) with other specialties, e.g. radiologists, neurologists, pediatricians:  
     
Are you a Member of a national or regional neurosurgical society in your country:


 
Name of that Society:  
 
Do you already have some surgical or neurosurgical instruments at your disposal? If so, please state which kind:
(e.g. Cranial Set, Spinal Set, Bipolar Coagulation Set, High-Speed Drill and/or a Microscope:)
Do you have a CT scanner:
 
Do you have an Ultrasonic Surgical Aspirator at your disposal:
 
What are your main reasons for requesting the neurosurgical equipment you have applied for?
(Please state your reasons and precise exactly what you require)
     
Sponsor Information    
Do you already have a Sponsor:
 
Full Name of the Sponsor:  
Street:  
City and Country:  
Postal Code:  
Email:  
Tel No:  
Fax No:  
If you have no Sponsor, please state why you think your neurosurgical department should be considered for a donation:  
 
Information on how to declare the shipment / which shipping documents are necessary for your country:  
     
Date  
Signature  
     
   
 
N.B: If your request is approved, the person making the bank transfer should kindly instruct the bank to indicate the correct reference number corresponding to the neurosurgical equipment requested, in order that the payment can be easily identified on its receipt.