Physician Education Course Application Form - Education by Merit Medical

Course*

Preferred Course Type*

Date and Location*

Preferred Course Date and Location

Preferred Course Date and Location Preferred

Preferred Course Date and Location

Name*

First Last

Facility Name*

Facility Location*

City State / Province / Region ZIP / Postal Code Country

Type of Facility*

Academic/Teaching institution
Private/Community based

Phone*

Email*

Your Position at Facility*

Current Localization Technology

Estimated number of breast conservation cases/month

0-10
11-25
26-50
51+

Have you evaluated any technologies aside from what you’re currently using?

VCF Experience - Vertebroplasty, Mechanical Cavity Creation*

No experience
< 50 cases
50-100 cases
> 100 cases

Please mark the conditions you treat:*

Spinal Tumor Ablation Experience

No experience
< 25 cases
25-50 cases
50-100 cases

Radial Experience*

No experience
< 50 cases
50-100 cases
> 100 cases

Distal Radial Experience*

No experience
1-10 cases
10-25 cases
25+ cases

Please indicate your primary interest for attending the course:*

Both Peritoneal Dialysis and HeRO Graft
Peritoneal Dialysis Only
HeRO Graft Only

Please indicate your primary interest for attending the course:*

Both HeRO and Surfacer
HeRO only
Surfacer only

Please indicate which course you would like to attend. Please select one per day.*

HeRO Graft Only - Friday
Percutaneous Peritoneal Dialysis Only - Friday
Laparoscopic Peritoneal Dialysis Only - Saturday
Combination: HeRO Graft and Laparoscopic Peritoneal Dialysis - Friday and Saturday
Combination: Percutaneous and Laparoscopic Peritoneal Dialysis - Friday and Saturday

Hero Graft Implantation Experience*

Peritoneal Dialysis Implantation Experience*

Medical Specialty*

Interventional Cardiology (not applicable to Melbourne)
Interventional Radiology
Neuro Interventional Radiology
Vascular Surgeon

Medical Specialty*

Vascular Surgeon
Transplant Surgeon
General Surgeon

Medical Specialty*

Electrophysiologist

Medical Specialty*

Interventional Radiology
Urology

Your Position at Facility*

Attending Physician or Surgeon
Clinical Support Staff
Fellow

Your Position at Facility*

Attending Physician or Surgeon (This course is currently limited to physicians who have completed their fellowship)

Fellowship Completion Date*

Year of IR Fellowship completion*

Number of embolization procedures you currently perform per year*

A minimum of one embolization procedure per week (no fewer than 52 embolizations annually) is strongly recommended.

Number of stenting procedures you perform per year*

Number of CRT cases you perform annually*

Experience with Radial Access*

No experience
Less than 10 % cases performed via radial artery
10-25% cases performed radially
25-50% cases performed radially
50-75% cases performed radially
More than 75% cases performed radially

Have you attended another Merit education program and if so, which one?

Please discuss the current level of collaboration/working relationship with your facility’s Urology department?*

What imaging equipment is available in the procedural lab? (fluoro, DSA, cone beam, etc.)*

Please note that cone beam CT imaging is required.

How were you referred to us*

Your Merit Representative

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I'm interested in receiving more information on related courses from Merit Medical.
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Required*

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Physician Education Course Interest Form

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Physician Education Course Interest Form

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