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Robert Smith Sr. Director, Quality Medication Delivery Baxter ...

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COLLEAGUE VOLUMETRIC INFUSION PUMP (Battery)<br />

Customer Reply Form<br />

(Important Product Information Letter Dated February 25, 2005)<br />

Facility Name and<br />

Address:<br />

Reply Confirmation !<br />

Completed By:<br />

(Please print name)<br />

Title:<br />

(Please o!i!!!L<br />

Telephone Number<br />

(including Area Code)<br />

We understand the contents of the letter and have disseminated this information to our<br />

staff and to other services, facilities, or home patients, as applicable.<br />

Signature/Date:<br />

(REQUIRED FIELD)<br />

To order the battery harnesses with protection circuit: Please complete additional<br />

information below<br />

Please send battery harnesses with protection circuit (part number BHRNSKlT) for the number of I<br />

infusion pumps listed below:<br />

2M8151 COLLEAGUE Single Channel Infusion Pump<br />

2M8153 COLLEAGUE 3 Channel Infusion Pump<br />

2M8161 COLLEAGUE CX Single Channel Infusion Pump<br />

2M8163 COLLEAGUE CX 3 Channel Infusion Pump<br />

COLLEAGUE and <strong>Baxter</strong> are registered trademarlcs of <strong>Baxter</strong> International, Inc. 2005-011 MD.

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