Exhibits and Grants Request

Thank you for considering OmniGuide as a potential partner in your educational or research endeavor. OmniGuide’s Compliance Committee meets periodically to review all complete requests. Your request is only deemed complete when it is received with an agenda or supporting promotional materials.

    Please fill out this form as completely as possible:



    Request type: Check all that apply

    In-kind donation

    Lab: Cadaver and/or live animal

                   Total # of days

                   Total amount requested (dollars)

    Lab: Non-cadaver and/or live animal

                   Total # of days

                   Total amount requested (dollars)

    Educational grant request

                   Total amount requested (dollars)



    Reusable equipment requested:
    (please indicate how many of each item you are requesting)

       OmniGuide surgical laser(s) & laser cart(s)

       OmniGuide pair(s) of laser safety goggles

       OmniGuide Surgical handpiece instrumentation set(s)

       Domain Surgical FMX Generator(s)

    Please note that the above materials are required to be returned to OmniGuide following the event.



    Disposable equipment requested:
    (please indicate how many of each item you are requesting)

       OmniGuide Surgical flexible fiber(s)

       Tank(s) of Helium

       Domain Surgical FMX surgical instrument(s)

       Domain Surgical FMX Power Module(s)

    Please note that the above materials are disposable and should be discarded following the event.



    Shipping information

    Does delivery address have a loading dock? YesNo

    Does delivery address have a pallet jack? YesNo



    Payment information

    If grant is made out to individual HCP, please provide NPI and state of licensure:

    If grant is made out to HCO, please provide HCO name and Tax ID number:



    Please attach a copy of the event agenda:



    Please attach a copy of any related promotional documents or other relevant related documents:



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    Please note that OmniGuide requires a minimum of 30 days to consider and process all in-kind donation and grant requests. Any request made fewer than 30 days from the required deadline will not be considered. Also note that OmniGuide administers this program without the involvement of its sales department. Should you have questions related to a request, please contact compliance@omni-guide.com directly rather than contacting your local sales representative.