Receipt Verification Form for Product Notification # 62-1382

Please confirm receipt of the Product Notification 62-1382, by completing and submitting receipt verification form below. If you have trouble completing and/or submitting the form, please complete and submit the manual form provided in the product notification.

Account # (if known):

Company/Hospital Name:

Address:

Address 2:

City:

State/Province

Zip/Postal Code

Country:

Contact First Name:

Contact Last Name:

Contact Phone Number:

Contact Role:

Contact Email Address:

Provide Total # of Sysmex XN modules in your lab:

Provide Serial #(s) from at least one of the XN modules (located under front cover):

Please confirm the receipt of this Product Notification: