VUL DIT FORMULIER IN EN STUUR HET TERUG PER FAX/E-MAIL
Kenmerk Roche Diabetes
Care:
SB_RDC_2018_02
Medisch artikel:
Accu-Chek
®
Aviva en Accu-Chek
®
Performa
teststrips
Fabrikant:
Roche Diabetes Care
Probleem:
Belangrijke informatie over bepaalde lotnummers Accu-Chek
®
Aviva en Accu-Chek
®
Performa teststrips die een hoger aantal
stripfouten voorafgaand aan de dosering of mogelijk onjuiste
resultaten laten zien
Formulier ontvangstbevestiging
Stuur dit bevestigingsformulier naar Roche Diabetes Care:
•Per e-mail: almere.dc@roche.com
•Per fax: 036-5394801
Naar het postadres: Roche Diabetes Care
Antwoordnummer 400
1300 WB Almere
Ik bevestig dat ik de informatie in deze veiligheidsmaatregel van 9 mei 2018
over de hierboven vermelde medische artikelen ontvangen, gelezen en
begrepen heb en dat ik de gevraagde acties uit zal voeren.
Formulier ingevuld en teruggestuurd door:
Naam (IN HOOFDLETTERS):
Functie van degene die dit formulier heeft
ingevuld:
Bedrijfsnaam:
Telefoonnummer:
E-mail:
Adres:
Datum: (dd-mmm-jjjj):
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