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Request for Procedural Deep Sedation Simulation Training Session
Requests should be made at least 4 weeks prior to the planned date of your event. Approval will be sent via email. Please note that fields marked with an asterisk (*) are mandatory.
I also need propofol privileges.
No
Yes
In order to proceed with scheduling your deep sedation simulation session, we need information regarding dates/possible times you are available. This will help us find times slots that do not impact our daily regularly scheduled departmental teaching sessions. You will then receive an Outlook invitation with proposed time and date. Please provide at least 3 dates and a range of times that you are available for your deep sedation training. If you would prefer these sessions be scheduled by your assistant, please provide that person's name. Thanks for your help with this process.
1st Date Choice:*
2nd Date Choice:*
3rd Date Choice:*
Faculty Physician Name:*
Faculty Department:*
Phone:*
E-mail Address:*
Pager Number:
Department Contact Name:
Department Contact E-mail Address:
MFK (only charged if scheduled time is missed):
Additional Comments for Sim Center :