Sterile Processing - Loaner Instrument Agreement
* Indicates required information
Loaner Items Information
Name of System(s):
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Company Name:
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Contact Person:
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Contact Phone Number:
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Set Name:
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Number of Sets:
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Surgeon Name:
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Date of Procedure:
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(mm/dd/yyyy)
Patient Name:
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Type of Loaner:
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One-Time Use Loan
On Going Evaluation Loan
Method of Sterilization:
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STERRAD (Not for use with implants)
ETO (Sent Group Health- requires 48 hours)
STEAM (Vacuum / 270F temp / 4 minutes)
STEAM (Extended Cycle 1)
STEAM (Extended Cycle 2)
Terms of Agreement
VMMC will not be held liable for missing instruments and/or prostheses without sterilization parameters, complete inventory lists, and the counting of items with the company representative at time of delivery. Courier services are not held liable by Sterile Processing Departments for missing items - this is between vendors and couriers.
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I Accept
All sets must be removed within 48 hours of the completion of the procedure for which the sets were used. All missing instruments and/or prostheses must be reported to SPD leadership within 2 hours of the completion of the procedure for which the sets were used.
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I Accept