58
BTS
Bioengineering
appendix
Operator of the device
(delete not applicable)
health professional
patient
lay user
other:
(specify)
Date of system installation
(MM/DD/YYYY)
Device available for
evaluation?
(Do not send to FDA)
yes
no
Returned to BTS S.p.A.
or its agents on:
(MM/DD/YYYY)
Concomitant medical products and therapy dates
(do not report products that were used to treat the event)