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Section 4-7 - Decontamination Certificate
User Manual
DECONTAMINATION CERTIFICATE
ENSURE THAT ITEMS RETURNED TO YOUR SUPPLIER ARE
DISINFECTED IN ACCORDANCE WITH THE APPROPRIATE HOSPITAL
PROCEDURE FOR EQUIPMENT OF THIS TYPE
A COPY OF THIS FORM MUST BE COMPLETED AND ATTACHED TO
THE OUTSIDE OF THE CARTON WHEN RETURNING THE PRODUCT TO
YOUR SUPPLIER. WITHOUT THIS FORM BEING VISIBLE THE COURIER AND/OR YOUR SUPPLIER ARE AT LIBERTY TO REFUSE HANDLING
OF THE PRODUCT.
I hereby certify that the machine referred to in this
document by model number and serial number has been
disinfected in accordance with Hospital Procedure
Model No: ____________________________________
Serial No:
____________________________________
Hospital:
____________________________________
Name:
____________________________________
Signature: ________________
Ref: PICO-EVO UM 41 09/11 Rev.C
Date: ____________
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