RA 3540155 – HeartSine samaritan PAD

Medical Device Product Defect Correction End User Notification Response Form

RA 3540155 – HeartSine Defibrillators
Country*
Please select below which applies to you:*

I confirm I possess a HeartSine samaritan DefibrillatorI do NOT possess a HeartSine samaritan Defibrillator
Distributor (if known)*
Which Authorised Distributor did you purchase your HeartSine defibrillator from?
Serial Number Information
Please provide the serial number of your HeartSine defibrillator and answer the following questions. Click + to add additional serial numbers if you have multiple affected HeartSine defibrillators.
If you have further distributed any affected product, please contact Stryker Post Market at:

postmarketssp@stryker.com
Disclaimer
I acknowledge that I have received and understood the associated notification, and that all requested actions have been completed.

I have performed the requested actions in Appendix 1 and understand that I should perform the recommended instructions on the Maintenance Supplement once every three months.
Name*

First NameLast Name
Business / Facility Name*
Email*
Phone
Note
If you were contacted regarding a specific SN, please provide this SN
Signature*

Clear
If you have any questions with regards to filling in this form, please contact:

Stryker Post Market:

Email: postmarketssp@stryker.com
and Stryker will provide assistance.
Should be Empty:

Medical Device Product Defect Correction End User Notification Response Form