TR-100 Transforaminal Set Order Form

If you would like to order the TR-200 or TR-100XL sets, please contact Customer Service at (516) 277-9000 or customerservice@elliquence.com

TR-100 Transforaminal Order Form

Name

First

Last

Phone

Ship To

City

State/Province

Zip/Postal

Physician / Facility Name

Intended Procedure

Date Needed By

Expected Return Date

How many endoscopes will you need with this order?

Do You Need a Surgi-Max Ultra and Double Footswitch?

Yes

Trigger-Flex Quad Pro (DTFQM-31) Amount Needed

Trigger-Flex 31 (DTF-31) Amount Needed

Recommended - 16g Spine Needle (DFX-N6/1) Amount Needed

18g Spine Needle (DFX-N8/1) Amount Needed

Specific Instructions and/or Additional Equipment Needed

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