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Email*

Phone*

First Name*

Last Name*

Title*

Healthcare Facility/System*

For PAs, NPs or First Assists, please provide the surgeon name with whom you practice:

City*

State* State*AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Where is the MagDI System in your approval process?* Where is the MagDI System in your approval process?* Haven't started In progress Complete

Are you affiliated with an Ambulatory Surgery Center (ASC)* Are you affiliated with an Ambulatory Surgery Center (ASC)* Yes No

VAC/VAT Contact Full Name*

VAC/VAT Contact Title*

VAC/VAT Contact Email*

VAC/VAT Contact Phone*

Are you currently performing SADI?* Are you currently performing SADI?* Yes No

How Many Years Have You Been Practicing?* How Many Years Have You Been Practicing?*N/A1-55-1010+

How Many Revisions Do You Perform Annually?* How Many Revisions Do You Perform Annually?*None1-1010-2020+