PROFILE INFORMATION First Name Last Name Title (MD, DO, Other) Years In Practice Start Date (MM/DD/YY) State Licensure & License Number Physician Email Website LOCATION INFORMATION Primary Location Location/Practice Name Street Address Suite Number City State StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Telephone Secondary Location Location/Practice Name Street Address Suite Number City State StateAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Zip Code Telephone Additional Hospital/Surgery Center Affiliations 1. 2. 3. 4. 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ATTUNE™ Knee System Partial Knee System TRUMATCH™ Personalized Solutions VELYS™ Insights & Patient Path VELYS™ Robotic-Assisted Solution Other DePuy Synthes Product(s) Shoulder ProceduresPlease check all shoulder procedures in which you use DePuy Synthes products. Shoulder Arthroscopy Shoulder Replacement Outpatient Shoulder ReplacementPlease check all DePuy Synthes products you use for shoulder replacement. DELTA XTEND™ Reverse Shoulder System GLOBAL UNITE™ Platform Shoulder System TRUMATCH™ Personalized Solutions Other DePuy Synthes Product(s) Spine ProceduresPlease check all spine procedures in which you use DePuy Synthes products. Adult Deformity Surgery Adult Degenerative Surgery - Cervical Adult Degenerative Surgery - Lumbar Fracture/Trauma Surgery Less Invasive Surgery Navigation Pediatric/Adolescent Surgery Tumor Surgery Vertebral Body Augmentation Outpatient Deformity CorrectionPlease check all DePuy Synthes products you use for deformity correction procedures. MAXFRAME AUTOSTRUT™ System Other DePuy Synthes Product(s) Rib FixationPlease check all DePuy Synthes products you use for rib fixation procedures. MatrixRIB™ Fixation System Other PEAK® Platelet Rich Plasma Johnson & Johnson MedTech Sales Consultant Name & Contact Information EDUCATION & TRAINING YYYY-YYYY Program/School City/State YYYY-YYYY Program/School City/State YYYY-YYYY Program/School City/State YYYY-YYYY Program/School City/State Certifications AUTHORIZATION HAVE YOU EVER BEEN EXCLUDED, DEBARRED OR SUSPENDED FROM PRACTICING MEDICINE BY ANY FEDERAL OR STATE AUTHORITY OR PROFESSIONAL SOCIETY? Yes No Terms & Conditions I hereby give my permission to Johnson & Johnson MedTech, its legal representatives and those acting under Johnson & Johnson MedTech authority, to list the information provided above in the Physician Locator service. This information is intended for use by residents of the United States. 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