Airway Mannequin Loan Request Form

Thank you for your interest in the Airway Mannequin Loan Program. Please consult the booking calendar and complete the form below. Please note that you will be contacted shortly to confirm shipping.

Your Contact Information

Once this form is submitted we will contact you to confirm the loan request. Please use this area to provide the contact details for the person who will confirm this request:

Mannequin Loan Details

Please indicate which mannequin(s) you would like to request for your community:

Pricing

Please note that the credit cards are the only method of payment accepted for this program.

Desired Length of Loan

Please indicate the length of time you would like to have the equipment in your community:

Desired Start Date

Please indicate when you would like to recieve the equipment:

Date

Shipping Details

Please use this area to provide the contact details for the local person who will receive the equipment in your community:

Program Objectives

Please select the objective(s) which apply to your intended use the equipment:

Accreditation

This program is eligible for self-learning credits for both physicians and specialists. Please note that Mainpro+ and MOC Section 2 credits require the completion of short reflective exercises in order to claim credits.

Please indicate which credits you are interested in claiming:

Please click submit and an RCPD team member with contact you to confirm your request.