EQUIPMENT CHECKLIST #:

DEMO FORM REQUEST DATE:

DEMO FORM - INTEGRA CUSA EXCEL

CUSTOMER: PHILIPPINE SOCIETY OF ANESTHESIOLOGIST ADDRESS: MARRIOTT

DELIVERY DATE: NOV 21, 2023
DELIVERY TIME: 1:00 PM PURPOSE:
CONTACT PERSON: ALLY ✘ CONVENTION/POST-GRAD/ WORKSHOP
POST QUALIFICATION OR ANY BIDDING RELATED, VTC
POSITION: MARKETING OFFICER
TRANSACTION
PULL OUT DATE: PRODUCT DEMO/PRESENTATION
PULL OUT TIME: LIVE CASE

DIVISION CODE REGION CODE LOCATION AREA CODE DIVISION AREA CODE MARKETING CODE
SI MM MM10 SI-MM4 SI-STI

CODE DESCRIPTION QUANTITY (DEMO) QUANTITY (CTM)

ECO BAG FOR CONVENTION 260

REQUESTED BY: ENDORSED for APPROVAL BY: APPROVED BY:

ROBERT VERGARA MONICA SANTILLAN

Signature over Printed Name / DATE Signature over Printed Name of IMMEDIATE SUPERIOR Signature over Printed Name / DATE

DEMO&SAMPLE Page 1
 EQUIPMENT CHECKLIST #:
DEMO FORM REQUEST DATE:

DEMO FORM - MEDTRONIC ENERGY-BASED DEVICES (EBD)

CUSTOMER: ADDRESS:
DELIVERY DATE:
DELIVERY TIME: PURPOSE:
CONTACT PERSON: CONVENTION/POST-GRAD/ WORKSHOP
POST QUALIFICATION OR ANY BIDDING RELATED, VTC
POSITION:
TRANSACTION
PULL OUT DATE: PRODUCT DEMO/PRESENTATION
PULL OUT TIME: LIVE CASE

DIVISION CODE REGION CODE LOCATION AREA CODE DIVISION AREA CODE MARKETING CODE
SI MM MM2 SI-MM2 SI-EBD

FORCEFX8GEN SCG VLFT10GEN VLLS10GEN

CODE DESCRIPTION QUANTITY (DEMO) QUANTITY (CTM)

E6008B MONOPOLAR FOOTSWITCH
E6009 BIPOLAR FOOTSWITCH
LS0300 LIGASURE SINGLE FOOTSWITCH
E0017 UNIV ACTIVE ADPT
E2999 CORD MONOPOLAR DAVINCI 10'
UC8009 UNIVERSAL CART
VLFTCRT UNIVERSAL GENERATOR CART
SCB SONICISION BATTERY PACK X1
SCST1 SONICISION STERILISATION TRAYX1
SCT12 SONICISION TORQUE WRENCH X12
E2450H BUTTON PENCIL W 3M CORD X50
E7507 POLYHESIVE II REM RET EL W/CORD
E7510-25 POLYHESIVE II PED RET EL X25
E7512 NEONATAL POLYHESIVE II PR ELEC
VL2610 RELIANT DISP PENCIL W HOLSTERX50
LF1212A SML LIGASURE JAW SEALER/DIV
LF1520 LIGASURE 5MM BLUNT TIP 20CM
LF1537 LIGASURE 5MM BLUNT TIP LAP X6
LF1637 LIGASURE 5MM BLUNT TIP INST
LF1737 LIGASURE MARYLAND JAW 37CM
LF4318 LIGASURE IMPACT
SCD13 13CM CORDLESS U/S DISSECTOR
SCD26 26CM CORDLESS U/S DISSECTOR
SCD391 SONICISION U/S DISSECTOR X1
SCD396 SONICISION U/S DISSECTOR
SCD48 SCD48//48CM CORDLESS U/S DISSECTOR
ADDITIONAL:
PVE-1500 AVR

REQUESTED BY: ENDORSED for APPROVAL BY: APPROVED BY:

Signature over Printed Name / DATE Signature over Printed Name of IMMEDIATE SUPERIOR Signature over Printed Name / DATE

MEDTRONIC EBD Page 2

 EQUIPMENT CHECKLIST #:
DEMO FORM REQUEST DATE:

DEMO FORM - INTEGRA CUSA EXCEL

CUSTOMER: PSGS-PALES CONVENTION 2023 ADDRESS: SHANGRILA MACTAN, CEBU

DELIVERY DATE: JULY 11, 2023
DELIVERY TIME: 9AM PURPOSE:
CONTACT PERSON: ROBERT VERGARA ✘ CONVENTION/POST-GRAD/ WORKSHOP
POST QUALIFICATION OR ANY BIDDING RELATED, VTC
POSITION: MARKETING OFFICER
TRANSACTION
PULL OUT DATE: PRODUCT DEMO/PRESENTATION
PULL OUT TIME: LIVE CASE

DIVISION CODE REGION CODE LOCATION AREA CODE DIVISION AREA CODE MARKETING CODE
SI VIS CVIS1 SI-CVIS1 SI-CUSA

CODE DESCRIPTION QUANTITY (DEMO) QUANTITY (CTM)

✘ CUSAEXCEL9 CUSA EXCEL + CONSOLE 1
C3600 EXCEL 23kHz TUBING SET
✘ C3601 C3601 Excel 36kHz Tubing Set 1
C4601S EXCEL 23kHz STANDARD TIP
✘ C4612S EXCEL 36kHz STANDARD TIP 1
✘ C5600 EXCEL TIP TORQUING SET 1
✘ C4616S C4616S Excel 36kHz CUSA SaberTip 1
✘ 150000090 EXCEL FOOTSWITCH 1
✘ C0005 EXCEL CONTAMINATION GUARD 1
C2600 EXCEL 23kHz STRAIGHT HANDPIECE
✘ C2602 EXCEL 36kHz STRAIGHT HANDPIECE 1
C2623 EXCEL 23kHz STERILIZATION CASE
✘ C2636 EXCEL 36kHz STERILIZATION CASE 1
✘ C4617S C4617S Excel 36KHz Shear Tip 1
✘ C4611S C4611S Excel 36kHz Curved Extended Micro 1
C5601 23kHz DISPOSABLE WRENCH
C5602 36kHz DISPOSABLE WRENCH
ADDITIONAL:

REQUESTED BY: ENDORSED for APPROVAL BY: APPROVED BY:

Signature over Printed Name / DATE Signature over Printed Name of IMMEDIATE SUPERIOR Signature over Printed Name / DATE

INTEGRA CUSA Page 3

 EQUIPMENT CHECKLIST #:
DEMO FORM REQUEST DATE:

DEMO FORM - PURITAN BENNETT 840 (PB840) VENTILATOR

CUSTOMER: ADDRESS:
DELIVERY DATE:
DELIVERY TIME: PURPOSE:
CONVENTION/POST-
CONTACT PERSON: POST QUALIFICATION OR
GRAD/ WORKSHOP
POSITION: ANY BIDDING RELATED,
PRODUCT
PULL OUT DATE: VTC TRANSACTION
DEMO/PRESENTATION
PULL OUT TIME: LIVE CASE

DIVISION CODE REGION CODE LOCATION AREA CODE DIVISION AREA CODE MARKETING CODE
LSM SLUZ SLUZ1 LSM-SLUZ1 LSM-PB

CODE DESCRIPTION QUANTITY (DEMO) QUANTITY (CTM)

4840220DIUAEN PURITAN BENNETT 840 VENTILATOR
407627000 GB UPGRADE KIT BIL
407632600 806 220V ENGLISH FRENCH X1 (COMPRESSOR)
407637000 GB UPGRADE KIT TC
407640500 NEOMODE ADAPTER PLATE X1
407640800 FILTER/WATER TRAP,DISP X12/CA (NEO DISP FILTER)
407812800 GB UPGRADE KIT VV+
407820400 GB PAV+ UPGRADE KI
10019217 INTL ENG RM UPGRADE K
10020407 INTL ENG TREND UPGRAD
10035086 COMPRESSOR MOUNT CART
10035875 INT ENG LEAK COMP UPG
10045581 4 HR CHARGING CIRCUIT
10045589 HUMIDIFIER KIT COMPRESSOR CART
10051496 INT ENG 840 NEOMODE 2
400061200 TEST LUNG
403200600 FLEX ARM
407030500 FILTER EXHALATION REUSABLE X1 (EXPIRATORY FILTER)
407460000 RE/FLEX FILTER 22MM X1 (INSPIRATORY FILTER)
407464700 COLLECTOR VIAL
407469800 HOSE ASSY OXY BS5682-NIST (OXYGEN HOSE)
407471300 HOSE ASSY AIR BS5682-NIST (COMPRESSED AIR HOSE)
AGAP6000UK AERONEB PRO SYSTEM INTL
6503-N02 Disposable Ventilator Breathing Circuit w/ Nebulizer, Adult
6503-N03 Disposable Ventilator Breathing Circuit Child
XAV0007 Disposable Ventilator Breathing Circuit (Infant)
CT-11322 Adult Dual Breathing System 1.8 m with Exhalation Tube and Pressure Tub
CT-16630 Disposable Ventilator Breathing Circuit w/ Exhlation Valve, Adult
CT-16635 Disposable Ventilator Breathing Circuit w/ Nebulizer, Adult
CT-16918 Anethesia Parallel Wye Circuit - 1.5 m w/o Elbow Connector
CT-17200 Pediatric Anesthsia Circuit Bi-wye 1.5 m, Elbow w/o Luer Lock Port
CT-17602 Disposable Ventilator Breathing Circuit Child
CT-18901 Infant breathing circuit, two water traps, with connectors
CT-19221 ID: 12mm F&P Heated Wire System (Single) - Besmed
CT-19223 ID: 12mm F&P Heated Wire System + Chamber (Single) - Besmed
CU-68307 Disposable Swivel Smoothbore 150mm, 15M, 15F/22M
FL-70313 HMEF w/ Luer Lock Port (15M/22F, 22M/15F), Single Packing
FL-70211 Filter w/ Luer Lock Port (15M/22F, 22M/15F), Single Packing
HC-73138 Humidification Chamber - Auto feeding, Disposable, Single packing
HC-73018 Humidification Temperature Probe - 1.5 m (60") in Length
ADDITIONAL:
152M GENTEC OXYGEN REGULATOR
152-QO GENTEC AIR REGULATOR
24-7323P CHROME FERRULES
3222-AIR-NT2 HOSE FITTING AIR
800-VH1500-220 HUMIDIFIER VH-1500 (220V)
G-315001 Mounting Bracket for Humidier
G-314004 REUSABLE ADULT CHAMBER (W/ SCROLL)
G-314005 REUSABLE NEONATAL HUMIDIFICATION CHAMBER

MEDTRONIC PB840 Page 4

 EQUIPMENT CHECKLIST #:
DEMO FORM REQUEST DATE:

DEMO FORM - PURITAN BENNETT 840 (PB840) VENTILATOR

CUSTOMER: ADDRESS:
DELIVERY DATE:
DELIVERY TIME: PURPOSE:
CONVENTION/POST-
CONTACT PERSON: POST QUALIFICATION OR
GRAD/ WORKSHOP
POSITION: ANY BIDDING RELATED,
PRODUCT
PULL OUT DATE: VTC TRANSACTION
DEMO/PRESENTATION
PULL OUT TIME: LIVE CASE

DIVISION CODE REGION CODE LOCATION AREA CODE DIVISION AREA CODE MARKETING CODE
LSM SLUZ SLUZ1 LSM-SLUZ1 LSM-PB

CODE DESCRIPTION QUANTITY (DEMO) QUANTITY (CTM)

NBU1818/JU1808 Oxygen Hose PB840 (407469800)
PVE-1500 AVR
AVR MOUNT
EXTENISION CORD
FAB. HUMIDIFIER MOUNTING KIT POWDER COAT PAINTING
FAB. MOUNTING BRACKET

REQUESTED BY: ENDORSED for APPROVAL BY: APPROVED BY:

Signature over Printed Name / DATE Signature over Printed Name of IMMEDIATE SUPERIOR Signature over Printed Name / DATE

MEDTRONIC PB840 Page 5

 EQUIPMENT CHECKLIST #:
DEMO FORM REQUEST DATE:

DEMO FORM - NIHON KOHDEN HUMMING VUE

CUSTOMER: ADDRESS:
DELIVERY DATE:
DELIVERY TIME: PURPOSE:
CONTACT PERSON: CONVENTION/POST-GRAD/ WORKSHOP
POSITION: POST QUALIFICATION OR ANY BIDDING RELATED, VTC TRANSACTION
PULL OUT DATE: PRODUCT DEMO/PRESENTATION
PULL OUT TIME: LIVE CASE

DIVISION CODE REGION CODE LOCATION AREA CODE DIVISION AREA CODE MARKETING CODE
LSM VIS CVIS2 LSM-CVIS2 LSM-HFOV

CODE DESCRIPTION QUANTITY (DEMO) QUANTITY (CTM)

10010701001 HUMMING VUE MAIN UNIT NIST
10010309003 TEST LUNG
10010402001 SUPPORT ARM FOR NEONATE
10010702001 STAND FOR HUMMING VUE
10010702002 MANUAL BREATH/HFO SI REMOTE CONTROLLER
10010702003 HUMMING VUE ARM BLOCK
10010702004 MANUAL BREATH/HFO SI REMOTE CONTROLLER HOLDER

10010709001 HUMMING VUE PISTON

10010709002 TRAY FOR DRAINAGE
10010808002 IMPEDANCE VALVE FOR NEONATE
10020704001 PATIENT CIRCUIT (VUE)
10020705004 DISPOSABLE CIRCUIT HUMMING
10020705005 SUPPORT ARM HOSE CLIP HUMMING BRISE
10080302002 PROXIMAL FLOW SENSOR
10080702003 PROXIMAL FLOW SENSOR CABLE
10500711015 POWER CABLE (220/240V)
31010403001 O2 SENSOR SET
ADDITIONAL:
800-VH1500-220 VADI HEATED HUMIDIFIER VH-1500 (220V)

G-314005 VADI REUSABLE NEONATAL HUMIDIFICATION CHAMBER

REQUESTED BY: ENDORSED for APPROVAL BY: APPROVED BY:

Signature over Printed Name / DATE Signature over Printed Name of IMMEDIATE SUPERIOR Signature over Printed Name / DATE

NH HUMMING VUE Page 6

 EQUIPMENT CHECKLIST #:
DEMO FORM REQUEST DATE:

DEMO FORM - ZOLL EAGLE MRI II

CUSTOMER: ADDRESS:
DELIVERY DATE:
DELIVERY TIME: PURPOSE:
CONTACT PERSON: CONVENTION/POST-GRAD/ WORKSHOP
POST QUALIFICATION OR ANY BIDDING RELATED, VTC
POSITION: TRANSACTION
PULL OUT DATE: PRODUCT DEMO/PRESENTATION
PULL OUT TIME: LIVE CASE

DIVISION CODE REGION CODE LOCATION AREA CODE DIVISION AREA CODE MARKETING CODE
LSM NMIN NMIN2 LSM-NMIN2 LSM-ZV

CODE DESCRIPTION QUANTITY (DEMO) QUANTITY (CTM)

EAGLE II VOLUME AND PRESSURE TARGETED PORTABLE
800-EGL2-02
CRITICAL CARE VENTILATOR SYSTEM
816-0731-01 ROLL STAND
499-0009-01 KIT, MRI CIRCUITS, EGL2

820-0130-00 PEDIATRIC/ADULT, SINGLE-LIMB,WYE

VENTILATOR CIRCUIT
INFANT/PEDIATRIC, SINGLE-LIMB,WYE VENTILATOR
820-0131-00
CIRCUIT 12FT.
499-0010-01 ACCESSORY KIT, EGL2
465-0027-01 DISK FILTER
465-0028-01 FOAM FILTER
499-0010-01 CD OPERATIONAL MANUAL
ADDITIONAL:
152M GENTEC OXYGEN REGULATOR

REQUESTED BY: ENDORSED for APPROVAL BY: APPROVED BY:

Signature over Printed Name / DATE Signature over Printed Name of IMMEDIATE SUPERIOR Signature over Printed Name / DATE

ZOLL EAGLE Page 7

 EQUIPMENT CHECKLIST #:
DEMO FORM REQUEST DATE:

DEMO FORM - SMITH AND NEPHEW COBLATOR II

CUSTOMER: ADDRESS:
DELIVERY DATE:
DELIVERY TIME: PURPOSE:
CONTACT PERSON: CONVENTION/POST-GRAD/ WORKSHOP
POST QUALIFICATION OR ANY BIDDING RELATED, VTC
POSITION:
TRANSACTION
PULL OUT DATE: PRODUCT DEMO/PRESENTATION
PULL OUT TIME: LIVE CASE

DIVISION CODE REGION CODE LOCATION AREA CODE DIVISION AREA CODE MARKETING CODE
LSS MM MM10 MIS-MM4 LSS-SNP

CODE DESCRIPTION QUANTITY (DEMO) QUANTITY (CTM)

EC8001-01 COBLATOR II CONTROLLER (240V)
10101 FLOW CONTROL VALVE
10863 FOOT CONTROL
ARC06149-G FLOW CONTROL CABLE
ADDITIONAL:

REQUESTED BY: ENDORSED for APPROVAL BY: APPROVED BY:

Signature over Printed Name / DATE Signature over Printed Name of IMMEDIATE SUPERIOR Signature over Printed Name / DATE

SN COBLATOR II Page 8
 EQUIPMENT CHECKLIST #:
DEMO FORM REQUEST DATE:

DEMO FORM - MERIL

CUSTOMER: ADDRESS:
DELIVERY DATE:
DELIVERY TIME: PURPOSE:
CONTACT PERSON: CONVENTION/POST-GRAD/ WORKSHOP
POSITION: POST QUALIFICATION OR ANY BIDDING RELATED, VTC TR
PULL OUT DATE: PRODUCT DEMO/PRESENTATION
PULL OUT TIME: LIVE CASE

DIVISION CODE REGION CODE LOCATION AREA CODE DIVISION AREA CODE MARKETING CODE
LSS VIS WVIS1 LSS-WVIS2 LSS-SUR

QUANTITY
CODE DESCRIPTION
(DEMO)

REQUESTED BY: ENDORSED for APPROVAL BY: APPROVED BY:

Signature over Printed Name / DATE Signature over Printed Name of IMMEDIATE SUPERIOR Signature over Printed Name /
D/ WORKSHOP
ANY BIDDING RELATED, VTC TRANSACTION
TATION

MARKETING CODE
LSS-SUR

QUANTITY (CTM)

APPROVED BY:

Signature over Printed Name / DATE

 EQUIPMENT CHECKLIST #:
DEMO FORM REQUEST DATE:

DEMO FORM - SMITH & NEPHEW (ORTHO)

CUSTOMER: ADDRESS:
DELIVERY DATE:
DELIVERY TIME: PURPOSE:
CONTACT PERSON: CONVENTION/POST-GRAD/ WORKSHOP
POST QUALIFICATION OR ANY BIDDING RELATED,
POSITION:
VTC TRANSACTION
PULL OUT DATE: PRODUCT DEMO/PRESENTATION
PULL OUT TIME: LIVE CASE

DIVISION CODE REGION CODE LOCATION AREA CODE DIVISION AREA CODE MARKETING CODE
SI MM MM4 SI-MM4 SI-CUSA

QUANTITY
CODE DESCRIPTION QUANTITY (CTM)
(DEMO)
✘

REQUESTED BY: ENDORSED for APPROVAL BY: APPROVED BY:

Signature over Printed Name / DATE Signature over Printed Name of IMMEDIATE SUPERIOR Signature over Printed Name / DATE
 EQUIPMENT CHECKLIST #:
DEMO FORM REQUEST DATE:

DEMO FORM - MEDTRONIC LAP TOWER

CUSTOMER: ADDRESS:
DELIVERY DATE:
DELIVERY TIME: PURPOSE:
CONTACT PERSON: CONVENTION/POST-GRAD/ WORKSHOP
POST QUALIFICATION OR ANY BIDDING RELATED, VTC
POSITION:
TRANSACTION
PULL OUT DATE: PRODUCT DEMO/PRESENTATION
PULL OUT TIME: LIVE CASE

CODE DESCRIPTION QUANTITY (DEMO) QUANTITY (CTM)

MLW-2623C-DC IKEGAMI FULL 26" MONITOR, MEDICAL GRADE
ITP PRO CART WITH VARIABLE HEIGHT SUPPORT ARM
PT.9005.902
(FLEXION PORT)
05.0090L HIGHTRANS LIGHT CABLE, 4.8X2300mm , AUTOCLAVE
200 LED, LED LIGHT SOURCE WITH MULTI LIGHT GUIDE
05.0740LED
ADAPTER
19211 DISPOSABLE INSUFFLATOR FILTER BOX 25 PCS
95.3730 FLEXIVISION 10
SET FLEXISCOPE FV10 CAMERA CONTROLLER + CAMERA
95.3751
HEAD WITH ENDOCOUPLER ZOOM
FXII HD-SCOPRE, 10X344mm, VIEW DIR. 0°, WIDE ANGLE
11.0031A
AUTOCLAVABLE
FXII HD-SCOPRE, 10X344mm, VIEW DIR. 30°, WIDE
11.0043A
ANGLE AUTOCLAVABLE
F104 40L INSUFFLATOR FOR LAPAROSCOPY
KU.3345.991 MONITOR BRACKET
P101.A P101 LAPAROSCOPIC PUMP 230V
USB300UEEM 1TB 2 REMOTE TRIGGER CABLES, MEDICAPTURE
Z0454-01 TUBESET, INFLOW, REUSABLE, 20 CYCLES

Z1415-01 REUSABLE INSUFFLATION HEATING TUBE (100 CYCLES)

Z1425-01 TUBESET, OUTFLOW, REUSABLE, 20 CYCLES

Z1426-01 TUBESET, VACUUM, REUSABLE 20 CYCLES
HIGH PRESSURE HOSE FOR BOTTLE GAS DIN
Z5044-01
CONNECTION
ADDITIONAL:

REQUESTED BY: ENDORSED for APPROVAL BY: APPROVED BY:

Signature over Printed Name / DATE Signature over Printed Name of IMMEDIATE SUPERIOR Signature over Printed Name / DATE

MEDTRONIC LAP TOWER Page 12