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?

Your Position at Facility

Physician
Surgeon
Fellow

What is your specialty?

How many vein procedures do you perform each month?

What treatment modality do you prefer? (Rank from most to least)

Foam
Glue
Laser
MOCA
RF

What percentage of your patients are treated with Foam?

100%
50 – 99%
<50%

What percentage of your patients are treated with Glue?

100%
50 – 99%
<50%

What percentage of your patients are treated with Laser?

100%
50 – 99%
<50%

What percentage of your patients are treated with MOCA?

100%
50 – 99%
<50%

What percentage of your patients are treated with RF?

100%
50 – 99%
<50%

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

Please indicate which course you would like to attend*

Percutaneous Peritoneal Dialysis
Laparoscopic Peritoneal Dialysis

Hero Graft Implantation Experience*

Peritoneal Dialysis Implantation Experience*

Medical Specialty*

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

Medical Specialty*

Vascular Surgeon
Transplant Surgeon
General Surgeon

Medical Specialty*

Electrophysiologist

Medical Specialty*

Interventional Radiology
Urology

Your Position at Facility*

Attending Physician or Surgeon
Fellow

Your Position at Facility*

Physician
Clinical Support Staff

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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Physician Education Course Interest Form

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