Synthes Patient Specific Plate Contouring (PSPC)
Request for Quote
Please send:
To:
1. Completed “Request for Quote” form
1. Fax: 610-719-6533
e-mail: pspc@synthes.com
2. CT Scan/Optical Disc from radiology (with
scanner type, date of scan, patient
name/number on disc).
2. Attn: PSPC
1329 West 121st Avenue
Westminster, CO 80234
Please Reference Synthes CT Scanning Protocol.
Or e-mail: pspc@synthes.com for FTP instructions.
* Patient name or number:___________________
* Surgery Date: _________________
* Surgeon name: ___________________________
* Hospital name: ___________________________
Account Number:_______________
Office phone number:_______________________
Office fax: ______________________
Primary e-mail: ____________________________________________________________
Secondary contact name: ____________________________________________________
Secondary e-mail: _________________________
Secondary fax: __________________
* Consultants Name:________________________
* Titanium Plate Selection (Please check all that apply)
Plate Type
System
Condylar Head
(For 2.4 LRP Only)
Straight
2.0mm Mandible Locking Plates (MLP)
Condylar Head
Angle, Left
2.4mm Locking Reconstruction Plate (LRP)
Angle, Right
2.0mm Thick MatrixMANDIBLE
Condylar Head Add On
Quantity =
Double Angle
2.5mm Thick MatrixMANDIBLE
2.8mm Thick MatrixMANDIBLE1
Questions?
Contact Synthes PSPC at:
1 866-332-7486
e-mail: pspc@synthes.com
This Patient Specific Plate Contoured Implants will be supplied with the understanding that the surgeon will
make the sole determination for its use and application.
* = Required Information
Office Use Only
1
Date Received:
Not Available in Double Angle
106743100
Page 1 of 2
Synthes Patient Specific Plate Contouring (PSPC)
Request for Quote
Approximate size, location and shape of defect (please draw/annotate defect).
Synthes will send images based on the CT data to the surgeon that can be annotated.
Please specify how you would like the defect modeled (e.g. removed, replaced with bar section,
opposite side mirrored, etc.)
Notes:
Special Shipping Instructions:
106743100
Page 2 of 2