HCP Expense Form – Steelhead Surgical

HCP Expense FormMadeline Kincaid2023-05-09T13:27:46-07:00

Submitting Rep Name *

First

Last

Activity Name *

Date / Time *

Date

Time

Expense Total Amount *

List All Arthrex/Agency Employees (Include Title & Territory) *

Non-HCP Attendees (Include First and Last Name) *

Total HCP Attendees *

Recipient Name *

First

Last

Recipient Type *

NPI Number/State License Number *

Recipient Name *

First

Last

Recipient Type *

NPI Number/State License Number *

Recipient Name *

First

Last

Recipient Type *

NPI Number/State License Number *

Recipient Name *

First

Last

Recipient Type *

NPI Number/State License Number *

Recipient Name *

First

Last

Recipient Type *

NPI Number/State License Number *

Recipient Name *

First

Last

Recipient Type *

NPI Number/State License Number *

Procedure & Product's Discussed *

Follow-up Plan *

Attach Receipt *

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