Resensation® surgeon submission form

* denotes required field

first name*

middle name

last name*

title

MD
DO

practice information

practice name*

office address*

street address suite city state zip code

office phone*

practice website or surgeon bio page*

additional practice location

I have a second office

second practice name (if different than primary)

second office address*

street address suite city state zip code

second office phone (optional)

second office website (optional)

affiliated hospitals

name(s)

education and training

undergraduate degree

Format example: “Stanford University”

medical degree

Format example: “University of Texas Southwestern Medical School”

residency

Format example: “MedStar Georgetown University Hospital”

fellowship

Format example: “New York University Medical Center”

additional training

Please list any additional training or other certification programs you have completed

board certification*

Format example: “American Board of Plastic Surgery”

image upload

headshot

Max. file size: 50 MB.

Please upload the highest resolution possible

Resensation

Do you currently offer the Resensation surgical technique to your patients? The Resensation technique is defined as performing breast neurotization through the reconstruction of one or more nerves in the breast(s) utilizing processed nerve allograft tissue and a coaptation aid.*

yes
no

If no, are you interested in offering your patients this technique as an option?*

yes
no

Do you have access to processed nerve allograft tissue and other required items/services to perform the procedure?*

yes
no

Please provide the number of breast reconstruction surgeries you perform on an annual basis, broken down by type.

autologous tissue breast reconstruction*

implant breast reconstruction*

tissue-expander to permanent implant

direct to implant

Please select all breast reconstruction procedures where you offer Resensation.

implant breast reconstruction
autologous flap breast reconstruction
aesthetic flat closure breast reconstruction

Are you trained in microsurgery or in microscope-assisted surgical nerve repair?*

yes
no

Have you ever trained in, or performed, the Resensation breast neurotization technique utilizing processed nerve allograft?*

yes
no

Please provide details regarding the number of cases you have performed using the Resensation surgical technique*

Axogen also has a surgeon locator on axogeninc.com. Would you also like your profile listed on the locator on axogeninc.com?*

yes
no

As a Resensation surgeon locator participant, we require office staff in-service training twice annually to ensure staff is knowledgeable about your listing and the Resensation procedure. Please provide us a practice key contact to coordinate these sessions.

key contact first name

For internal use only

key contact last name

For internal use only

key contact job title (office manager, surgical coordinator, nurse, NP, PA, MA, etc.)

For internal use only

key contact phone

For internal use only

key contact email

For internal use only

is there a secondary point of contact you would like included?

secondary contact first name

For internal use only

secondary contact last name

For internal use only

secondary contact job title (office manager, surgical coordinator, nurse, NP, PA, MA, etc.)

For internal use only

secondary contact phone

For internal use only

secondary contact email

For internal use only

By submitting your request, you are indicating that you agree to the following:

I hereby do grant Axogen permission to use contact information for me and my practice in its physician locator tool as part of its effort to connect patients to physicians who treat peripheral nerve injuries.
I understand and agree that the information submitted and indicated for inclusion in the locator tool may be made publicly available on one or more Axogen websites within the search function or may be provided to a patient by an Axogen associate.
I understand and agree that the contact information for my name and for my practice may be made publicly available in one or more specialty-specific physician locator search tools that Axogen may develop for its website(s) depending on my medical specialty(ies).
I understand and agree that Axogen will seek to make sure all information is accurate, however Axogen will bear no responsibility or liability for (i) inaccurate, incorrect, incomplete, or outdated information provided to patients through the physician locator tool; (ii) any use or misuse of the information provided hereafter; or (iii) the decision by Axogen to discontinue the physician locator tool at any time and without notice to participant.
I understand and agree that I may update my contact and practice information, or otherwise modify the permission granted at any time by sending written notice to info@resensation.com.
I understand and agree that the information I submit to be included in the locator tool will be governed by Axogen’s Privacy Policy for its website(s).
I understand and agree that I may receive and use certain content, marketing materials, downloadable assets and intellectual property of Axogen (collectively, “Axogen IP”) to educate, market and promote the Resensation^® technique and such use will be governed by Axogen’s Terms and Conditions for its website(s).
I understand and agree that I cannot violate, infringe, misappropriate or conflict with any of Axogen’s intellectual property rights in Axogen’s IP, including without limitation, Axogen’s patents and trademarks.
I understand and agree that Axogen reserves the right to exclude my information in the online physician locator tool program.
I confirm that my institution allows my name to be used for the purposes described above.
I have no disclosures regarding allegations/convictions of crimes against me, open malpractice liability claims or changes in the status of my medical licensure.

NPI number*

surgeon email*

†NPI Number and provider email will be used for verification purposes only. They will not be published as part of the physician locator tool program. The surgeon locator tool was created to help patients find surgeons who perform breast neurotization using the Resensation surgical technique. The Resensation surgical technique is defined as reconstructing one or more nerves in the breast(s) utilizing processed nerve allograft tissue and a coaptation aid. Axogen reviews all applications to ensure that all criteria are met. Only qualified, proficient surgeons will be permitted to join the website.