Download Equipment / Supplies needed: To be completed by DLAM Staff

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SURGERY/PROCEDURE ROOM SCHEDULING REQUEST FORM – UNTHSC DLAM
To be completed by PI/TECH: (Send completed form to Tito Nelson via e-mail:
[email protected] or fax to 817-735-0559)
Investigator Information:
Name of PI: Telephone #: Department: Protocol #: Species: Grant #: Animal ID #: Title of Protocol: Contact persons E‐mail address: Surgeon/Person performing procedure: Assistant(s): DLAM assistance required? Yes No (If Yes, fill out information below) DLAM Services/Assistance Needed (Mark all that apply) Perform surgery Animal prep Monitor anesthesia Recover animal Estimated time needed to perform surgery: DLAM Surgery/Procedure Room reserved? Yes No Surgery/Procedure Room Number requested: Surgical dates and times requested (preferred) Date/time: Date/time: Date/time: Date/time: Date/time: Date/time: Date/time; Date/time: DLAM Equipment / Supplies needed: To be completed by DLAM Staff Date requested received: Veterinarian in attendance: Date Surgery Scheduled for: Date Surgeon notified: Method of notification: Comments: Date PI notified:
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