Sample Order Form

ProLong - Non-Stimulating 21G continuous block catheter set
Teflon Coating, Tuohy Borst Adaptor, 0.2 mm Needle Tip Exposure
  Block Bevel, 19G Needle
   PL19050GC 50mm (2") Useable Needle Length
   PL19100GC 100mm (4") Useable Needle Length
   PL19150GC 150mm (6") Useable Needle Length
  Tuohy Bevel, 18G Needle
   PL18050TGC 50mm (2") Useable Needle Length
   PL18100TGC 100mm (4") Useable Needle Length
   PL18150TGC 150mm (6") Useable Needle Length
 
ProBloc - Single Injection PNB Needle Sample Selection
Sleeve Insulation, Needle Only
  Block Bevel, 22G Needle
   HN1-40 30mm (1.2") Useable Needle Length
   HN1-80 70mm (2.75") Useable Needle Length
   HN1-100 90mm (3.5") Useable Needle Length
Sleeve Insulation, Injection Set
  Block Bevel, 22G Needle
   HN2-40 30mm (1.2") Useable Needle Length
   HN2-80 70mm (2.75") Useable Needle Length
   HN2-100 90mm (3.5") Useable Needle Length
Sleeve Insulation, Injection Set and Stimulating Wire
  Block Bevel, 22G or 20G Needle
   HN3S-25 22G Needle, 15mm (.6") Useable Needle Length
   HN3S-40 22G Needle, 30mm (1.2") Useable Needle Length
   HN3S-80 22G Needle, 70mm (2.75") Useable Needle Length
   HN3S-100 22G Needle, 90mm (3.5") Useable Needle Length
   HN3S-120 20G Needle, 110mm (4.7") Useable Needle Length
   HN3S-150 20G Needle, 140mm (5.5") Useable Needle Length
 
ProBloc SC
Teflon Coating, Injection Set and Stimulating Wire
  Block Bevel, 25G Needle
   PC25025C 25mm (1") Useable Needle Length
   PB25040C 40mm (1.5") Useable Needle Length
 
ProBloc II - 25G Single Injection Needle
Teflon Coating, Injection Set and Stimulating Wire
  Block Bevel, 22G or 20G Needle
   PB22050GC 22G Needle, 50mm (2") Useable Needle Length
   PB22080GC 22G Needle, 80mm (3") Useable Needle Length
   PB20100GC 20G Needle, 100mm (4") Useable Needle Length
   PB20120GC 20G Needle, 120mm (4.7") Useable Needle Length
   PB20150GC 20G Needle, 150mm (6") Useable Needle Length
     
**For ContiStim® samples, please contact your local U.S. or International representative**
Delivery Address and Contact Information
*Name:
*Title:
*Company (or Facility) :
*Department:
*Address:
*City:
*State:
*Zip:
*Country:
*Phone:
*Email:
NOTE: Indicate the brand and model of stimulator to be used in order to receive the appropriate interface lead set or adaptor.
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