Medical Devices Interim Order Request Form

Protected B When CompletedMedical Devices Interim Order Request Form Please send the completed form along with a copy of each device label to hc.medicaldevices.covid19.instrumentsmedicaux.sc@canada.ca Part I: Company IdentifierCompany Name and AddressCompany Name:Canadian Address:Manufacturer Name and Address Company Name:Manufacturer’s AddressKey ContactName:Phone Number:Email address:Part II: Type of Request - enforcement discretion Import device not meeting all regulatory requirements Sell device not meeting all regulatory requirementsPart III: Product IdentifierProduct To be Imported /sold Name of ProductForeign Registration Number (if available) Please indicate country of registrationName of ProductMedical Device Establishment License Number or Medical Device License Number How are these devices not meeting all regulatory requirements? (i.e., Non-bilingual labelling, expired device etc.)?Part IV: Shipment Details (if available at time of application/notification)Date of Import:Port of EntryDestination:Tracking NumberQuantity:*Note: All information collected from this form will be protected according to the Government of Canada security standards. All government departments have to abide by the Access to Information and Privacy (ATIP) regulations that require us to protect private information. ................
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