Welcome to the 2021 ASC Forum Application

Please complete the form below to apply for the Virtual Forum. Make sure to complete the entire form and then click the blue "Continue" button. Please feel free to call Michelle Fetterer at +1 847-423-5127 with any questions. We look forward to reviewing your application!

Event: ASC Forum
First Name*
Last Name*
Your Title*
Pronouns*
Facility*
First Name on Badge if different from above
E-Mail*
Confirm E-Mail*
Work Address*
City*
State (two-letter abbreviation)*
ZIP/Postal*
Work Phone Number*
Cell Number*
Emergency Contact Person AND Phone Number*
 
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Independence Day is the Fourth of*
 
*These fields are required to have a value.

Please tell us about your organization:

How many ORs are in your facility?

How many exam/procedure rooms?

Does your ASC provide ambulance or other transportation?

Does your ASC operate as a single or multispecialty practice? Please list any and all specialties.

Which of the following best describes your ASC?

Tell us about your ASC and the community it serves (2-4 sentences). If you answered "none of the above" to the previous question, please describe here.

Tell us a little about yourself - your background, years in the industry and your current scope of responsibility (2-4 sentences). Sports fan, pet owner or cooking enthusiast? Tell us that too!

What is currently going well in your ASC?

What keeps you up at night regarding your ASC?

If you could ask a room full of your peers a question or two about their ASC, what would you ask?

What other ASC leaders or facilities would you recommend we invite to the Forum?


PROCUREMENT PLANS:

Are you responsible for the selection or recommendation of products and services for your ASC?

Room Cleaning Systems (UV, air, etc.): What is your ASC's projected need?

Sterile Processing and Decontamination Equipment: What is your ASC’s projected need?

Patient Positioners: What is your ASC’s projected need?

OR Tables: What is your ASC’s projected need?

Non-pharmacological, Multi-modal Nursing Intervention Products: What is your ASC’s projected need?

Surgical Lights: What is your ASC’s projected need?

Surgical Tools: What is your ASC’s projected need?

Scrubs/Uniform Rental: What is your ASC’s projected need?

Capital Equipment: What is your ASC’s projected need? Please describe.

Monitors/Cameras/Video Devices: What is your ASC’s projected need?

What are your ASC’s software needs in the next 6 to 18 months (data analytics programs, patient communication and scheduling systems, pre-certification systems etc.)?

Will you be building new operating rooms or updating your facilities over the next 12-18 months? If so, please indicate here:

Please tell us about any other acquisition plans over the next 6 to 18 months.

Please list 2-5 products or service companies you would like to learn more about.

Do you work with any GPOs? Are you part of an IDN? If so, which one(s)?

Do you have access to a camera on a computer?

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Please only click the "continue" button once. The application will take a moment to process your responses.