National Loaner Request Form

Company

This field is for validation purposes and should be left unchanged.

Loaner set fee

Loaner Sets are to be returned by the fourth day following the procedure for which the Loaner Set was requested. You may be charged for all missing components in the tray unless we are notified within 24 hours of the case. Any Loaner Set not received by Arthrosurface by the fourth day following a procedure may incur a $250 late fee in addition to a $50 late fee for every day thereafter that the Loaner Set has not been returned. Late fees are subject to change at any time. Arthrosurface may waive late fees due to extenuating circumstances at Arthrosurface’s sole discretion. Arthrosurface recommends that you reach out as soon as possible upon your realization that your loaner set may be late. You can reach Arthrosurface at nationalkits@arthrosurface.com to explain your situation. By clicking here, you acknowledge that Arthrosurface has the right to charge late fees for Loaner Sets that are not returned on time.

Director of Sales (Territory DOS)

First Last

Select Your Director of Sales (Territory DOS)*

DOS Email*

SALES REP NAME*

First Last

EMAIL ADDRESS OF REQUESTOR*

EMAIL ADDRESS OF RECIPIENT*

PHONE NUMBER OF REQUESTOR/RECIPIENT*

DISTRIBUTOR*

DATE OF ARRIVAL FOR KITS*

SURGERY DATE*

SURGEON*

First Last

FACILITY*

KITS NEEDED*

SHIPPING INFORMATION

TO: COMPANY NAME

TO: CONTACT NAME*

TO: ADDRESS (MUST BE FEDEX HOLD FOR PICK UP, OR WILL BE SIGNATURE REQUIRED)*

Street Address Address Line 2 City State ZIP Code

SPECIAL INSTRUCTIONS

SHIPPING METHOD*

FEDEX STANDARD OVERNIGHT

FEDEX PRIORITY OVERNIGHT

FEDEX Second Day

UPS Standard Overnight

UPS Priority Overnight

UPS Second Day

Consent

I consent to my data being stored according to the Privacy Policy

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