Socuron® — Sample Request Form

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1 Institution Information

Hospital / Institution Name *

Hospital Grade / Level

Total Number of Beds *

Number of Operating Rooms

ICU Beds

Department / Ward

2 Product & Sample Quantity

Product

Specification

Quantity Requested (vials) *

Intended Use *

Clinical evaluation Formulary addition Switch study Quality comparison Training Emergency stock

3 Justification for Sample Request

Note: Samples are for clinical evaluation only — not for resale. Please provide a clear clinical rationale.

Reason for Request & Clinical Need *

Expected Outcome / Evaluation Plan

4 Hospital Surgical Volume

Surgeries per Month *

General Anesthesia / Month

Emergency Surgeries / Month

RSI Cases / Month

ICU Patients w/ NMB / Month

Pediatric Surgery / Month

5 Estimated Monthly NMB Consumption

Instructions: Provide estimated monthly usage for each NMB agent currently used at your institution.

NMB Agent	Brand Used	Specification	Est. Monthly Vials	Primary Clinical Use
RocuroniumSocuron® (requested)
Rocuroniumother brand(s)
CisatracuriumNimbex® / others
AtracuriumTracrium® / others
VecuroniumNorcuron® / others
SuccinylcholineSuxamethonium
Total Estimated NMB Consumption / Month			0

Rocuronium: % of Total NMB Use

Cisatracurium: % of Total NMB Use

Current Formulary Status of Rocuronium

6 Reversal Agent & Monitoring

Reversal Agent(s) Available

Neostigmine + Glycopyrrolate Sugammadex (Bridion®) Edrophonium Other

Neuromuscular Monitoring Available

TOF (Train-of-Four) PTC (Post-Tetanic Count) Clinical assessment only Quantitative monitor

7 Contact for Follow-up

Contact Name *

Phone / Mobile *

8 Terms & Conditions

Samples are provided free of charge for clinical evaluation and formulary assessment only.
Samples must not be resold, redistributed, or used for commercial purposes.
The institution is responsible for proper storage, handling, and disposal of all samples.
Clinical use must comply with the institution's ethical review and informed consent procedures.
The requester agrees to provide evaluation feedback within 3 months of receiving samples.
The manufacturer reserves the right to approve, modify, or decline any request.

I have read and agree to the Terms & Conditions. *

You will receive a confirmation email after submission.

Socuron® Sample Request Form