Medical Product Evaluation Form

Medical Product Evaluation Form
This form is for the Product Evaluator to complete
Product Information
Description of Medical Product
Attach relevant brochures
Cancelof
Description of Clinical Application
Brand Name
Model Number
Manufacturer
Model Name
Price
Reason for Request
Reason for Evaluation
Other
Provide evidence of the product's benefits
Supplier Information
Name of Supplier
First NameLast Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Evaluation Requested by Product Evaluator
Name
First NameLast Name
Position
Organisation
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Does your practice change as a result of your evaluation/use of this product?
If yes, please explain how this product constitutes a change in the scope of your practice?
I declare that, to the best of my knowledge, I have no financial or other interests that could be considered as having any influence on my ability to fulfill my obligations properly and objectively in relation to the evaluation of this product.
Product Evaluator Signature
Clear
Date
MonthDayYear
Date
Should be Empty: