New/Replacement Clinical Product & Equipment Request Form

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Section 1: Requestor Information

Physician/Clinical Requestor

Service Line/Specialty

Requestor's Phone Number

Request Completed By

Section 2: Request Type

Request to trial product

As needed by clinical necessity, non-stock

Add product to inventory, regular use

If Approved, This Product Will

Please List Product Name and SKU For Each Requested Item

Section 3: New Product Information

Product/Equipment Name

Price Of Product/Equipment

All capital request must be approved by the Capital Committee.

Annual Anticipated Volume

Brief Description Of Intended Use; Procedure Or Diagnosis:

What Is The Benefit Of The Use Of The Requested Product/Equipment In Terms Of Impacting Cost, Quality and Outcomes (CQO)?

Product Standardization

Improves Clinical Outcomes

BHS Cost Savings Initiative

Premier/Ascend Program

Enhances Patient Satisfaction

Vendor Representative Name

Vendor Representative Phone Number

Vendor Representative Email

If There Is A Charge For The Trial, Please Provide The Cost Per Unit

If There Is A Product-Related Incident, What Will Be The Manufacturer, User And Hospital’s Liability?

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.

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

If Yes, Please Elaborate

Please Enter Your Initials

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