Graft Matching

Allograft Matching Request Form

GRAFT TYPE

SPORTS MEDICINE

LARGE GRAFTS

Contact Information:

REQUESTER NAME

REQUESTER EMAIL

SURGEON NAME

SURGEON EMAIL

OFFICE CONTACT

OFFICE CONTACT EMAIL

CONMED REP

CONMED REP EMAIL

REQUEST DATE

CPM

CONMED REP PHONE

ACCOUNT NUMBER

FACILITY NAME

FACILITY CITY

FACILITY STATE

ZIP CODE

FACILITY PHONE

PLEASE INDICATE A PREFERENCE

FRESH

FROZEN

NO PREFERENCE

Frozen Meniscus w/ Tibia Plateau:

Frozen Meniscus w/ Tibia Plateau

430400^Whole Left Meniscus

430410^Whole Right Meniscus

430401^Hemi Left Medial Meniscus

430411^Hemi Right Medial Meniscus

430402^Hemi Left Lateral Meniscus

430412^Hemi Right Lateral Meniscus

Laterality:

Laterality

Left

Right

Either

Configuration:

Configuration

APC

Lg Graft

With Cuff

Without Cuff

Proximal

Distal

Whole

With Extensor Mech (BTB)

Additional Information:

Patient Diagnosis and Surgical Procedure

Comments

Attachments

NOTE: Films must contain both AP and LAT views. X-rays must have a magnification number.

Add another

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Specialty

Anatomy

Tissue Type

Procedure

Brand

ASPS Plastic Surgery the Meeting

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Allograft Matching Request Form