Sample new technology/procedure request form

Sample new technology/procedure form

[Name of hospital]

Physician name: ___________________________________________________________________
Date: ____________________________________________________________________________

What new technology/procedure do you plan to use?
_________________________________________________________________________________
_________________________________________________________________________________

Will the nursing staff or other staff need any special or additional education?
_________________________________________________________________________________
_________________________________________________________________________________

Will use of this technology/procedure require an operating room setup that is different from the norm?
_________________________________________________________________________________
_________________________________________________________________________________

Please give us the names of three hospitals that use this technology/procedure.
_________________________________________________________________________________
_________________________________________________________________________________

When would you like to begin using this technology/procedure?
_________________________________________________________________________________

Will this technology/procedure require the physician to attend any continuing medical education courses prior to its use? If so, please describe.
_________________________________________________________________________________
_________________________________________________________________________________

Please outline the qualifications needed by a physician to use this technology/procedure safely.
_________________________________________________________________________________
_________________________________________________________________________________

If you have any of the following information, please submit it:

a. Research concerning the proposed technology/procedure
b. Course materials
c. Manufacturer's materials
d. Food and Drug Administration approvals (if any)