Capintec Safety Alert Notice

Captus 4000e Safety Alert Notice

Please fill out this short form.
I acknowledge receipt and review of this CAPTUS 4000e SAFETY ALERT NOTICE for Captus 4000e Serial Number:blanks* .
Name

First NameLast Name
Title
Facility
Facility Address
Phone Number

Area CodePhone Number
Number of Thyroid Uptake patients per Week:
E-mail
example@example.com
Signature
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Captus 4000e Safety Alert Notice