Authorization for return of a medical device to the manufacturer

I am sending back device(s) to LABORATOIRES EUROSILICONE for evaluation.
I understand that the device(s) may be altered or destroyed for the purpose of this evaluation.
After evaluation, the device(s) may be retained or discarded by LABORATOIRES EUROSILICONE

Date :   Surgeon's name & signature:

Product complaint information

Patient initials or identifier : Year of birth :

Device N 1

Reference : Serial N : Lot N :
Date of implantation : Date of explantation :
Reason for surgery : augmentation reconstruction replacement of previous implant
Position of the device : right left
submuscular subglandular other :
Fill volume and any product mixed with saline (if applicable) :
Was the device damage during the explantation procedure : no <:8http://crl.microsoft.com/pki/crl/products/WindowsPCA.crl0  *H r''D9Kw}""Sa t0Yk%$@2>(PtR tE1))Y0%yϥj]C7*/a& 4UgEy>]Mru +=NԖJ`:DYP5|&bXd!z,|K]n6.`ڨlFouc@0 +70 +7  SubCA0 UF0U00  *H c9dޙ6c#jLEm9L_߈KDbN &i>/Hϔ#g4)zhTY<&exhy9йO1&G$ޢoanO696gKܢ!Z@;•8گ ղ{%ݧM̪WJ,Qť9-@\$O7t^>̇,`)- ,IpPf:=:1҃_W1S0O001 0 UUS1 0 UWA10URedmond10U Microsoft Corporation1+0)U "Copyright (c) 1999 Microsoft Corp.1806U/Microsoft Windows Verification Intermediate PCA a +;0 +0 *H  1  +7 0 +7 10  +70# *H  1N{%bN0 +7 1v0t@>Windows Media Security Catalogg0.http://www.microsoft.com/windows/windowsmedia 0  *H R ȼT1M}VlwBrj)rd$9& N֥3DhL.{E5|~jh#T%ڊ46d?p):7,4r0 *H  100g0S1 0 UUS10U VeriSign, Inc.1+0)U"VeriSign Time Stamping Services CA +)2 ^v0 *H Y0 *H  1  *H 0 *H  1 050128220003Z0 *H  1I'iK[_0  *H k f yhhr "xId߾I^&_:ӏi)%3PVn|^ƚe!$Nz£\vdz*s`=F4>mAt8^ (Lu8 鷿B= [¯E4!m*&m̟"<1j*ݙh/>$[/Sl6*yq-R+l0|7skv1ĘtEH(`U#"Lv |CCC0|  040axESPp