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Kapitex Healthcare Ltd, 1 Sandbeck Way, Wetherby, West Yorkshire, LS22 7GH, UKTel: 01937 580211 • Fax: 01937 580796 • Email: [email protected]
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.
