Mandatory Customer Record
In accordance to the Medical Devices Authority, appropriate customer records are to be maintained on the distribution up to retail distribution of the medical device to the end-user. All required information should be completed and any false information provided could result in a fine by the Medical Devices Authority. All Personal Data Privacy Act policies will be in place to protect your personal data.

MDA Approval Ref: (4) MDA.600-1/6/27
Date: 23 July 2021

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Customer's Name *
IC Number *
Phone Number *
Email Address *
Lot Number (Sample As Per Image) *
Captionless Image
Required
MFG Date (Sample As Per Image Above) *
Date of Purchase *
MM
/
DD
/
YYYY
Time of Purchase *
Time
:
Pharmacy/Clinic/Retail Outlet Purchased From *
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