Fresenius Medical Care GranuFlo Dissolution Unit II - Batch Analysis Form

P/N 450368 Rev. I—BATCH ANALYSIS FORM 41
Batch Analysis Form
Customer Information Form
Clinic Name: __________________________________________________________
Contact Name: ____________________Contact Phone Number: ________________
Clinic Fax Number: _________________ OR Email: _____________ @ ____________
Dissolution Tank Serial Number: ___________________________________________
Product Catalog Number: ________________________________________________
Important: Incorrect catalog number will affect the test results.
Lot Number: ___________________________________________________________
Date Sample Taken: _________________ Sample By: __________________________
NOTE: TO PREVENT BATCH ANALYSIS DELAYS, THIS FORM MUST BE
COMPLETE AND ACCURATE.