Schedule a Clinical Evaluation

I am interested in evaluating the following LigaSure™ instruments:
(select all that apply)

Open Instruments		Laparoscopic Instruments
	LigaSure™ V Open 20 cm Sealer/Divider Instrument		LigaSure™ V Sealer/Divider Instrument
	LigaSure Atlas™ 20 cm Sealer/Divider Instrument		LigaSure Atlas™ Sealer/Divider Instrument
	LigaSure Atlas™ 20 cm Hand Switching Sealer/Divider		LigaSure Atlas™ Hand Switching Laparoscopic Sealer/Divider
	LigaSure™ Axs Instrument		LigaSure™ Lap Instrument
	LigaSure Impact ™ Instrument 18 cm
	LigaSure™ Max Instrument
	LigaSure™ Std Instrument
	LigaSure Precise™ Instrument
	LigaSure™ Xtd Instrument

Name*

Title

Surgical Specialty

E-mail Address*

Primary Hospital

Address*

City*

State

Zip

Country

Secondary Hospital

Address

City

State

Zip

Scheduler's Name

Telephone*

Best time to call

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