Medical Device Procurement Form

Key information

Name of Recipient *

Name of Service *

Location where device will be based *

Requested by *

Financials

Is this for a capital funding request? *

Yes No

Device Details

Device Type *

Automatic Blood Pressure Monitor Sphygmomanometer All 3 cuff (blood pressure) sizes Stethoscope Pulse Oximeter Thermometer Non-standard (details to be provided below)

Any further information you would like to provide?

Reason for request *

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Medical Device Procurement Form