Northside Hospital
Surgical Services Inventory Addition Request
Product Name
Supply Type
Please Select
Supply
Implant
Equipment
Supply Category
Please Select
Blade
Catheter
Cautery
Drain/Tube
Drape
Dressing
Drill/Battery
Drill Bits/Burs
Equipment
Gloves
Implant
Instrument
Medication
Misc Supply
Needle
Pack
Staple
Suture
Syringe
Tray
Disposition
Please Select
Disposable
Reposable
Reusable
Usage Location
ALPH
BCC
GFS
MM
NSC
NSF
SS
TOWER
Does this item replace any existing item(s)?
Yes
No
If Yes, please provide Item Number and Description:
What Surgical Procedures will use this item?
List all physicians that are requesting to use this item:
Manufacturer
Catalog #
Size
Unit of Measure
Cost
Vendor Name
Vendor Address
Vendor Rep
Vendor Phone #
Coordinator/Supervisor Signature
Manager Signature
HSM Item Code
SIM Code
Date Entered
Should be Empty: