Section 1: Requestor Information

Section 2: Request Type

I Want To

Section 3: New Product Information

All capital request must be approved by the Capital Committee.

Is The Current Product Under An Existing Contract?
Reason For The Request (Check All That Apply)
Is This Product FDA Approved?
Is This Product Intended For Off Label Use?
Is There Medical Literature Supporting The Intended Use?
Is A Trial Of This Product Requested?
Will Product Be Provided At No Charge?

If none, please enter N/A.

Section 4: Conflict Of Interest Statement

Requesting Physician and/or Departments must complete this conflict of interest statement. This information will be shared with the VAC members and will be taken into consideration when discussing your request.  A potential conflict of interest issue does not disqualify someone from requesting the product.

Do you or an immediate family member own stock in the company (excluding mutual funds)?
Do you serve on the board of directors of the company?
Have you been employed as a consultant for the company?

Have you received any financial support from the company as listed below?

Funding For Research
Support For Presenting Continuing Education Or Other Professional Education Supported by The Company
Received An Education Grant
Received Travel Support
Other

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