RECEIPT OF COMMUNICATION/ RESPONSE FORM

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RECEIPT OF COMMUNICATION/ RESPONSE FORM

Please fill out and submit this receipt of understanding of the content outlined in this letter to CardioQuip as soon as possible (associated customer communication letter: "Urgent: Medical Device Correction/Removal Potential bacterial contamination in your MCH-1000 device").

Please complete the form below within 5 business days of receipt.

Email *

Acknowledgement of Receipt *

I have read and understand the notification and will take necessary actions.

Required

Customer Initial *

By initialing, I acknowledge that I have read and understand the notification and will take necessary actions.

Date

YYYY

Customer First Name *

Customer Last Name *

Title *

Facility Name *

Facility Street Address *

Facility City *

Facility ST *

Please select state or territory below:

Facility ZIP *

Please enter 5-Digit Zip

Facility Phone Number *

Any adverse events experienced relating to CardioQuip devices should be reported to CardioQuip or through FDA's MedWatch Program:

Phone: +1 (800) FDA-1088

Web: www.fda.gov/medwatch/report.htm

CardioQuip, LLC

8422 Calibration Ct.

College Station, TX 77845

USA

Tel: +1 (979)691-0202

Toll Free: 888-267-6700

www.CardioQuip.com

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