baf-gss

Kapitex Healthcare Ltd, 1 Sandbeck Way, Wetherby, West Yorkshire, LS22 7GH, UKTel: 01937 580211 • Fax: 01937 580796 • Email: sales@kapitex.com

www.kapitex.com

Request for customisation (BAF) GSS™/Dumon®

Please mark the adequate drawing and indicate:

ø1___________mm

ø2___________mm

ø3___________mm

L1 ___________mm

L1 ___________mm

L1 ___________mm

Patient name or number

Customer

Doctor’s Name

_________________________________________

Address

_________________________________________

_________________________________________

Telephone

_________________________________________

Stamp & signature for approval

Dimensioned drawingFor a stent that does not correspond to any of theabove drawings, please provide a dimensioneddrawing:

Distributor

Name

_________________________________________

Address

_________________________________________

Stamp & signature

Novatech

___________________________________ ___________________________

REF LOT

___________________________________ ____________________________

Official Representative Date/ Visa

___________________________________ ____________________________

Novatech hereby certifies that the custom madestent described above is manufactured in strictcompliance with the European Directive 93/42/CEannex 1.

It is in the prescribingdoctor’s responsibility todetermine whether thiscustom made stent issuitable for the patient.