Design and Engineering Services Request Form

Use this form for Anatomic Training Models. They are NOT a medical device.

Reference number

Requestor Name(Required)

Family name Given name

Position(Required)

Phone(Required)

Email(Required)

Facility/hospital/university(Required)

Department(Required)

Brief description of device and its use (e.g. surgical training model, machine component, visual prototype, virtual model)(Required)

Requested Supply Date (the date the device is to be used)

General part tolerance required (+/- 1 mm, +/- 0.5 mm, +/- 0.15 mm, less than +/- 0.15 mm)

Device usage conditions (e.g. temperature, mechanical strength requirements)

Device colour, texture, transparency

Surface finish requirements

Part bounding box size

Length (mm); Width (mm); Height (mm)

Quantity needed

Additional comments/requests

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