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- #2 D. SUSPECT MEDICAL DEVICE - - 1. Brand Name 2b. Procode 2. Common Device Name 3. Manufacturer Name, City and State (Continue page3) 3) (Continue on page 6. Relevant Tests/Laboratory Data, Including Dates (Continue page3) 3) (Continue on page 7. Other Relevant History, Including Preexisting Medical Conditions (e.g., allergies, pregnancy, smoking and alcohol use, liver/kidney problems, etc.) Lot # 4. Model # 5. Operator of Device Catalog # Expiration Date (dd-mmm-yyyy) Serial.

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