National Loaner Request Form

Loaner set fee*

Loaner Sets are to be returned by the fourth day following the procedure for which the Loaner Set was requested. You may be charged for all missing components in tray unless we are notified within 24 hours of the case. Any Loaner Set not received by Anika by the fourth day following a procedure may incur a $250 late fee in addition to a $50 late fee for every day thereafter that the Loaner Set has not been returned. Late fees are subject to change at any time. Anika may waive late fees due to extenuating circumstances at Anika’s sole discretion. Anika recommends that you reach out as soon as possible upon your realization that your loaner set may be late. You can reach Anika at arthrosurface@gmlx.us.com with a cc: to John Avery (javery@anika.com) to explain your situation. By clicking here, you acknowledge that Anika has the right to charge late fees for Loaner Sets that are not returned on time.

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Loaner set fee

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Director of Sales (Territory DOS)

First Last

Select Your Director of Sales (Territory DOS)*

DOS Email*

SALES REP NAME*

First Last

EMAIL ADDRESS OF REQUESTOR/RECIPIENT*

PHONE NUMBER OF REQUESTOR/RECIPIENT*

DISTRIBUTOR*

SURGERY DATE*

SURGEON*

First Last

FACILITY*

DATE OF ARRIVAL FOR KITS*

KITS NEEDED*

SHIPPING INFORMATION

TO: COMPANY NAME

TO: CONTACT NAME*

TO: ADDRESS (MUST BE FEDEX HOLD FOR PICK UP, OR WILL BE SIGNATURE REQUIRED)*

Street Address Address Line 2 City State ZIP Code

SPECIAL INSTRUCTIONS

SHIPPING METHOD*

FEDEX STANDARD OVERNIGHT

FEDEX PRIORITY OVERNIGHT

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