Provider Name
Provider Email
Category —Please choose an option—AdultPeds
Building —Please choose an option—JHOC ORRemoteWeinberg ORWilmer ORZayed OR
Room #
1st Case2nd Case
Line Placement —Please choose an option—Arterial LineCVPPA CatheterSpinal Drain Catheter
Central Line Kit —Please choose an option—Single LumenDouble LumenTriple LumenLong CordisShort Cordis
Central Line Kit Size —Please choose an option—3 fr. 5 cm3 fr. 8 cm4fr. 5 cm4 fr. 8 cm4 fr. 12 cm5 fr. 8 cm7 fr. 15 cm7 fr. 20 cm (double lumen)7 fr. 20 cm (triple lumen)16 fr. 16 cm (single lumen)
PA Catheter Type —Please choose an option—Regular SwanPace PortContinuous CO Swan
Endotracheal Tube —Please choose an option—EndotrolLaser TubeMLTNasal RaeNIMs TubeOral RaeStandard Hi-LOWSubglottic
Endotracheal Tube Size —Please choose an option—22.533.544.555.566.577.588.59
Laryngoscope Blade —Please choose an option—MacMiller
Laryngoscope Blade Size —Please choose an option—01234
Special Airway Supplies CMacGlidescopeFiberoptic CartBronchial BlockerMcGrathDouble Lumen ET Tube Tube Size
Regional Anesthesia Supplies Epidural Kit (Adult)Epidural Kit (Peds)Peds CaudelSpinal Tray
Anesthesia Equipment Additional Fluid WarmerBelmontBIS MonitorEcho MachineLevel-OneSonositeSpinal Drain Set-UpUltrasound - Site-Rite
# of Alaris Pumps and Channels —Please choose an option—2345678
Other Specific Request: (For Liver & TAA specify # of transducers)
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For questions about this form or technical problems: Technical Support
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