Tissue Tracking

This product contains human allograft tissue. In order to maintain allograft records, we request that your facility complete this form.

Date of implantation or Discard *

Reason for Discard *

Physcian Name: Last *

First *

Speciality

Facility Name *

ASC *

Clinic *

Hospital*

City *

Country *

Zip/Postal Code *

Office Telephone No *

Procedure description or CPT# *

Patient Facility Number *

Last Name *

Date of Birth *

Patient Zip Code *

Gender*

NOTE:

In accordance with JCAHO and FDA requirements, it is the responsibility of the healthcare practitioner to maintain recipient records for the purpose of tracking tissue after IMPLANTATION. This tissue tracking record is not a replacement or substitute for the physicians or facilities internal tissue tracking systems.