M S T:  80-watt Holmium:YAG Surgical Laser Service Request Form

Please Fax to 972-735-8020 or toll-free 866-572-7407 for Confirmation

Pricing includes delivery, setup, ANSI laser safety signs, ANSI laser safety eye wear, a certified laser operator, any necessary smoke evacuation systems and any and all arthroscopy, urology, plastic surgery, dermatalogic, ENT, Ob/GYN, general surgery, and/or gastroenterology delivery systems.  Spinal probes vary depending on the facility's equipment and surgeon's preference and are furnished based on surgeon’s preference.   Pricing varies with spinal probe requested.

• Submit one completed Laser Service Request Form (below) for each case scheduled, or call the MST office at 972-735-8003 or 800-765-9661, or page your account representative.
• MST schedules by the case. When the equipment is booked, please know the number of cases and type of procedure(s) for each case scheduled. This will enable us to insure that the right number and type of probes are delivered with the equipment.
• When the equipment is scheduled, please have the surgeon's name(s), phone number(s) and an office contact person.
• The equipment will be delivered and set up by our certified laser operators.
• The laser operator will operate the laser and assist the surgeon(s) and nursing staff throughout the procedure(s).
• A rental delivery form will be given to you immediately following the scheduled surgery.  A purchase order is due as soon as services are rendered.
• If there is a cancellation within 48 hours of the scheduled delivery, a cancellation fee will be invoiced.

Today’s Date: __________________________

Facility Name: ______________________________     Surgeon’s Name: _____________________________

Requested Date of Procedure: _______________________ Time of Procedure: _______________________

Length of Time Requested for Procedure:_____________________________

Type of Procedure: ____________________________   Patient’s Name: _____________________________

Requested by: ________________________________________________ (Signature Required)

Printed Name: ________________________________________________

Phone #_________________________________               Fax #_________________________________

Comments________________________________________________________________________________

_____Confirmed as requested                 _____Time unavailable                    _____Date unavailable

Comments________________________________________________________________________________

Signed____________________________________________________                Date________________