TranTien Foundation Surgical Equipments and Supplies Donation Form

I would like to donate the following surgical equipments/supplies:

__ Dermatomes and Mesher Systems - Zimmer, Padgett, Brown
__ Headlights - Welch-Allyn brand, with chargers for both 110V and 220V
__ Autoclaves - preferably the portable Midmark M-7 Speedclave model
__ Electro-cautery units - Valleylab "Force 40" in 110V and 220V
__ Dingman mouth gags
__ Disposable cautery pencils - sterilized
__ Microscope - Zeiss
__ Microsurgical instruments
__ Magnification loupe (at least 3X)
__ Hand surgery instruments
__ Maxillo-facial surgery including rhinoplasty instruments
__ Anesthesia machine and fiberoptic
__ Surgical supplies: sutures. Vicryl, pds, prolene, nylon marseline
__ Sterile half- or three-quarter sheets
__ Surgical gloves (sterile) sizes 6, 6-1/2, 7 and 7-1/2
__ Pressure garments for burn patients with keloid scar (any sizes, any part of body)


Contributor Information

First Name: _______________  Middle Intiial: ___  Last Name: _________________

Institution: __________________________________________________________

Address: ____________________________________________________________

Phone: __________________________ Email: _____________________________

__  I would like to have my name listed in the TranTien Foundation Sponsorship List
__  I would prefer to keep this donation anonymous
__  I would like to make this donation

     on behalf of _______________________________________________________

     or in memory of ____________________________________________________

Comment: ___________________________________________________________


Signature _______________________________________ Date ________________

Mail form to: 
TranTien Foundation Inc.
23823 Valencia Blvd # 220
Valencia, CA 91355