Mobile Lab Request Form

Please fill out this form to request a mobile lab event with Paragon 28.

Required Information

What agency are you with?*

Select or enter value

Region*

Select or enter value

Your First and Last Name*

Your Phone Number*

Your Email Address*

Start Date*

End Date*

If you only need the mobile lab for one day, the start date and end date should be the same.

Start Time

For events spanning multiple days please list the start time on the first day.

End Time

For events spanning multiple days please list the end time on the last day.

City*

State*

Lab Details

If the lab execution details are known, please complete the section below.

If you do not have this information now, it will be requested at a later date.

How many attendees are you expecting?

Which products do you plan to showcase?

Check all that apply.

Select or enter value

Please confirm that you will require a member of the TAR team present for your lab.

We will notify the TAR team of your request. Please be sure you and your team are coordinating with the TAMM assigned.

Please enter the name(s) of the surgeons being trained by the TAR team.

Please confirm that you will require a member of the Ex-Fix team present for your lab.

Please the name(s) of the surgeons being trained by the Ex-Fix team.

Do you plan to use human anatomical specimens?

Yes

Which specimen is preferred?

Select all that apply

Select or enter value

Do you plan to use sawbones?

Yes

How many sawbones are needed?

Please let us know which additional products you are interested in.

You are responsible for ordering these products through Marketing Materials. Please have them shipped directly to your address.

Any additional equipment needed?

If so, please list the details here.

Do you plan to offer food and beverages?*

Please note, the requesting agency is responsible for requesting food and beverage, this is separate from the Mobile Lab request.

Select

Who is providing the food and beverage?

Facility Information

If you have a preference for where the mobile lab is parked, please provide those details below.

If you do not have this information now, it will be requested at a later date.

Facility Name

Facility Street Address

Zip Code

Parking Details

Please list any general information regarding your preferred location here,

Facility Contact Name

Please provide the name of the person who approved us to be onsite or the person we can coordinate logistics with. This should NOT be a paragon employee or member of the requesting agency.

Facility Contact Phone #

Facilty Contact Email

*By registering, you agree to the below Compliance Terms & Conditions for the event. You agree to give Paragon 28 access to the contact information you provide to us to contact you about our products, marketing materials, and additional medical education content. You may unsubscribe from these communications at any time. For information on how to unsubscribe, as well as our privacy practices and commitment to protecting your privacy, please review our Privacy Policy.*

Compliance Agreement

Before submitting, confirm your understanding of the following terms and conditions:

All events must contain a robust agenda including scientific, educational, or business presentations that account for the majority of time of the event.

You may not pay for or provide any entertainment or recreational activity incidental to the event.

All attendees must have a legitimate business interest in the information provided. Participation of non-HCP attendees spouses and guests will result in disciplinary action. In the event a guest is present through no invitation of your own, you may not pay for that individual's costs; these costs must be paid for by the individual on a separate tab.

You may not pay for or provide more than 3 alcoholic drinks per HCP throughout the duration of the event. If possible, utilize a drink ticketing system to ensure compliance.

All meals must be modest and reasonably priced and may never exceed $150 pp, including tax and tip. No meals may be provided for virtual events or any event where P28 personnel is not present.

Within 7 days after the event, you are responsible for submitting a complete and legible sign-in sheet for all attendees when F&B is provided. You are welcome to create your own so long as it contains first and last name and NPI number (or title if no NPI). You are also responsible for producing an itemized receipt within that same time frame.

You are responsible for ensuring that a full and accurate CMS report relevant to the event is submitted by either you or the individual who submitted payment.

Failure to provide the documentation required by items 6 or 7 will result in $0 reimbursement or 100% commission reduction of the cost of the event as well as potential further discipline at the discretion of the Chief Compliance Officer.

Request for HCP consultant assistance is not a guarantee; the determination of whether the request is compliant and feasible will be made by internal HQ personnel. Salespeople may not request services from an HCP.

If you have any additional information or questions in regards to a specific event, or the event submission process, please contact Events & Tradeshow Manager Kristin Grunewald (kgrunewald@paragon28.com).

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