Sample new technology/procedure request form
Medical Staff Leader Connection, November 28, 2006
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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)
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