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Acknowledgement Form

Account Information

Customer Number/Consignee Number

Institution Name (E.G., Name of the Hospital, Health Care Organization) *

Institution Address *

Phone Number *

Country *

Customer Statement *

We confirm receipt of this field safety notice and completion of the required actions contained therein. We further confirm that our inventory does NOT include products affected by this notice.

We confirm receipt of this field safety notice and completion of the required actions contained therein. We further confirm our inventory DOES include impacted product. The use and further distribution of the affected products is stopped & all impacted inventory will be returned.

We confirm receipt of this field safety notice and previously submitted an acknowledgment form listing impacted products. However, we have identified additional impacted products. The use and further distribution of the affected products is stopped, and all additional impacted inventory will be returned.

Stock Status

Enter product details manually

Upload an excel file

Product Code *	Lot / Batch Number *	Quantity Returning (EA) *

NOTE: Please select the product number first to enable the selection of the corresponding lot number. If you cannot find a product number / lot number combination that you believe is in scope, please contact us using the information below or reach out to your local customer service agent.

Contact Information

Name *

Title *

Email *

Date *

I have read and acknowledge the <a href="https://www.teleflex.com/usa/en/legal/internet-privacy-policy/" target="_blank">Teleflex Privacy Notice</a>. *

By clicking 'Submit', I confirm that the information provided in this form is accurate and serves as my offical acknowledgement. *

Arrow Arterial, CVC, Epidural, PSI, & MAC Kits

EIF 000606

Acknowledgement Form