EMIGS Laparobowl Kit Contact Form

Thank you for continued support and interest in the EMIGS program. This form is the next step in confirming your contact information and getting your kit shipped.

Please note that each kit contains the following:

Laparobowl, pegs and suturing blocks
Penrose drains for practicing and preparing for the skills test.
Two 12mm ports.
A video dongle for connecting your trainer box to a laptop or computer.
A mini tripod and phone holder to connect your smartphone to our proctoring service.

Additional laparobowl kits can be purchased for a fee via our partner Inovus here: https://aagl.inovus.org/

Next steps: Kits are shipping, please allow 2-3 weeks for processing and shipping.

1. Residency Program Name - *This question is required.

2. Number of Residents in Program - *This question is required.

3. Residency Program Mailing Address (EMIGS kits must be shipped to an institution or hospital address) - *This question is required.

Institution / Hospital Name *This question is required.

Street Address *This question is required.

Apt/Suite/Office

City *This question is required.

State

Zip *This question is required.

Country *This question is required.

Phone Number

Website

4. Given you will be provided with a Laparobowl kit, does your program anticipate needing more than one kit? If so, please list the estimated quantity below.

5. Program Contacts - Most important is the contact person we will be working with regarding shipments and or scheduling (if other than program chair) *This question is required.

Space Cell	First Name	Last Name	Email Address
Department/Program Chair	Department/Program Chair: First Name	Department/Program Chair: Last Name	Department/Program Chair: Email Address
Program Director *This question is required	Program Director: First Name	Program Director: Last Name	Program Director: Email Address
Assistant Director	Assistant Director: First Name	Assistant Director: Last Name	Assistant Director: Email Address
Program Coordinator	Program Coordinator: First Name	Program Coordinator: Last Name	Program Coordinator: Email Address