This Verifies That the In-Service Has Been Completed to Our Satisfaction

FACILITY: / Reprocessor Type:

The endoscope listed below are currently in use by the facility. Any additional endoscopes must be verified so that the correct hook-up can be identified and used. This is accomplished by referencing the endoscope hook-up matrices for the specific brand and model of endoscope, which can be found on the Medivators website at: www.minntech.com/medivators.

Only Medivators validated endoscope hook-ups can be used. Medivators hook-ups are validated for proper endoscope connection and fluid flow, which is critical to ensuring the endoscope and its interior channels are high level disinfected and rinsed. Hook-ups CANNOT be modified or altered. Use of altered hook-ups is strictly prohibited and will NOT ensure endoscope decontamination or patient safety, and should never be used.

ENDOSCOPE INFORMATION
# / BRAND / MODEL # / MODEL QTY / HOOKUP / # / BRAND / MODEL # / MODEL QTY / HOOKUP
1 / 21
2 / 22
3 / 23
4 / 24
5 / 25
6 / 26
7 / 27
8 / 28
9 / 29
10 / 30
11 / 31
12 / 32
13 / 33
14 / 34
15 / 35
16 / 36
17 / 37
18 / 38
19 / 39
20 / 40

This verifies that the in-service has been completed to our satisfaction.

Facility Representative: / Title:
Signature: / Email: / Date:
In-Service Provider: / Signature: / Date:

Provide a copy of this sheet to the facility representative and fax completed form to:

Medivators Technical Support : FAX 1-866-421-7696