Resensation® surgeon submission form

first name*

middle name

last name*

title

MD
FACS
PharmD
MBChB

primary hospital or surgery center information

primary hospital or surgery center*

website*

office phone*

office contact email*

admin contact name

For internal use only

admin contact phone

For internal use only

admin contact email

For internal use only

practice logo

Accepted file types: jpg, gif, png, esp, Max. file size: 50 MB.

Please upload a high-resolution jpg, png or eps file

address

street address suite city (city only) state zip code

Additional primary hospital or surgery center

I have a second office

second primary hospital or surgery center

second office phone

second website*

second office contact email

second practice logo

Accepted file types: jpg, gif, png, Max. file size: 50 MB.

second address

street address suite city (city only) state zip code

affiliated hospitals

name(s)

education, certifications and awards

undergraduate degree

Format example "B.S. from Stanford University in California"

medical degree

Format example "University of Texas Southwestern Medical School in Dallas"

residency

Format example "Plastic surgery at Baylor College of Medicine in Houston"

fellowship*

Format example “Microsurgery at New York University Medical Center in New York”

additional training/certification(s)

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

board certification*

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 volume of breast reconstruction surgeries you perform on an annual basis.

autologous tissue breast reconstruction*

implant breast reconstruction*

tissue-expander to permanent implant

direct to implant

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*

Are you interested in an in-service training or educational materials for your support staff on the Resensation surgical technique with processed nerve allograft?*

yes
no

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*

*NPI Number will be used for verification purposes only. It 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.

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.