PASCAL
®
Synthesis Ophthalmic Scanning Laser Systems Page 135 of 141
88292-EN, Rev D
Decontamination Certification
Under the provisions of Postal Law, Title 18, United States Code, Section 1716 and
Department of Transportation regulations contained in CFR 49, Part 173.386 and 173.387,
“etiologic agents, diagnostic specimens and biological products…are nonmailable…”
The undersigned therefore certifies that the IRIDEX Corporation equipment being returned
herein by
Individual/Institution City, State/Province, Country
Has undergone decontamination with a commercially available germicide cleared for use as
a Hospital Disinfectant and is clean and free from biohazards, including – but not limited –
human or animal blood, tissue or tissue fluids or components thereof.
The undersigned also agrees to reimburse Iridex Corporation for any costs incurred in
decontaminating the enclosed equipment, in the event said item is received by Iridex
Corporation in a contaminated condition.
Model: PASCAL Synthesis Ophthalmic Scanning Laser System
Wavelength: ☐ 532 nm ☐ 577 nm
Serial Number:
Iridex Corporation
RMA Number:
Position/Title:
Name (Printed):
Signature Date (DD/MM/YYYY)
To Next Page
Loading...
