Medical Device Registration Form

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Medical Device Registration Form

Establishment Information

Establishment Name

City

Country

FDA Registration Number

Street Address

State

Postal Code

DUNS Number

Información de la persona de contacto del cliente

Contact Person Name

Job Title

Tel Number

Si es diferente del establecimiento mencionado anteriormente, proporcione la información de su empresa a continuación:

Street Address

State

City

Postal Code

Country

Tipo de operación del cliente

Please check the box that applies to you * Obligatorio

Manufacturer

Contract Manufacturer

Contract Sterilizer

Developer

Initial Importer

Foreign Exporter

Relabeler

Other (Explain)

Importador inicial de la FDA de EE. UU. (parte responsable en EE. UU. del cumplimiento de la FDA)

Initial Importer Name

DUNS Number

FDA Registration Number

Address

Phone Number

Fabricante

Manufacturer Name

FDA Registration Number

Address

Tel Number

Manufacturer Name

FDA Registration Number

Address

Tel Number

*Los dispositivos médicos deben ser productos terminados. Si tiene más dispositivos, envíe el resto por correo electrónico a ask@provisionfda.com .

Dispositivo médico - 1

Proprietary Name

Common Name

Device Classification

Product Code

510(k) Number

Dispositivo médico - 2

Proprietary Name

Device Classification

Common Name

Product Code

510(k) Number

Proprietary Name

Device Classification

Common Name

Product Code

510(k) Number

How did you hear about us? * Obligatorio

Google search

Newspaper or Magazine

Instagram

Facebook

Youtube

Website

Trade Show

Naver

Referred by

I accept terms & conditions

Thanks for submitting!

Dispositivo médico - 3

Fabricante - 2

13925 City Center Dr. Suite 200, Chino Hills, CA 91709 | Teléfono: +1-909-493-3276 (oficina) | Correo electrónico: ask@provisionfda.com

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