⚠ Clean Certified

This form must be completed and submitted to us prior to returning any instruments and/or devices, regardless of actual usage.

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RMA

Purpose

Evaluation

Loaner/Rental

Repair

Returns

Facility Name

Address

City

State/Province

Zip/Postal

Sterile Processing Manager Name

Phone

Purchasing Contact Name

Phone

Instrument Tracking Info - SKU/Catalog No. and Serial No.

Purchase Order No.

Please note - repair will not be performed unless a valid Purchase Order Number associated with the instrument is provided.

We hereby CERTIFY that the instruments contained herein have been cleaned and sterilized prior to shipping according to the following guidelines. Please choose one of the following:

Clean and disinfect immediately after use. DO NOT allow bio fluids or other medical residue/material to dry on the instrument; wipe clean and keep moist until the instrument reaches sterile processing. Rinse thoroughly (≥ 30 minutes) in lukewarm pH neutral water. Carefully scrub with soft brushes. Flush lumens and joints using a syringe filled with demineralized water. Use low-foaming, enzymatic cleaning solutions with a pH range of 6-8 and follow manufacturer’s instructions. Rinse again with demineralized water. Lubricate in a water-soluble instrument “milk” bath.

Sterilized wrapped devices using pre-vacuum cycle for 4 minutes at 270°F(132°C).

IN CASE OF NON-USE; we certify that these instruments/devices were never used in surgery nor came in contact with any contaminated device, and therefore do not require cleaning and or sterilization.

Product never opened.

Product opened but reviewed only outside of a surgical/lab environment.

Please explain the issue and the repair required.

Please Type in Your Full Legal Name for Electronic Signature

By typing my name above, I understand and agree that this form of electronic signature has the same legal force and effect as a manual signature.

(Optional) Please Upload an Image of Your Signature (jpeg, jpg, jpe, png, gif)

Maximum file size: 516MB

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Obtain a Return Authorization Number by completing this form. When received, we will return this form with an assigned RMA No. Once you receive the Return Authorization Number from us, please place it in a packing slip pouch. Please attach to the outside of the carton, making sure the “RMA” number can be seen through the pouch. Any packages that are received without a completed form are subject to refusal or a predetermined $900.00 cleaning fee. Any instrument that comes back contaminated and not cleaned will be immediately disposed. In case of additional questions or concerns, please call us at (800) 497-0851.

Please email us the Shipping tracking information to expedite your package.

Repair Form

⚠ Clean Certified

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