U.O.C. INGEGNERIA CLINICA E HTA Via Unità Italiana, 28 - 81100 CASERTA (CE) P.IVA 03519500619 – [email protected]  0823/445.111-291-247-455-108-239 -  0823/354983 Mod. Richiesta VIS01 Modulo di RICHIESTA APPARECCHIATURA ELETTROMEDICALE -IN VISIONELa presente richiesta deve essere inoltrata all’U.O.C. Ingegneria Clinica Aziendale tramite fax o email. L’Ingegneria Clinica, dopo la ricezione della richiesta, provvederà ad autorizzare la Società produttrice / distributrice ad installare l’AEM concordando le fasi di consegna, collaudo provvisorio e addestramento al personale, previ accordi con l’U.O. Richiedente. A cura del Servizio Ingegneria Clinica e HTA Protocollo Richiesta _____________________________________ Protocollo Ricezione _________________________________________ Data _________________________________________________________ Data ______________________________________________________________ Richiedente: Presidio / Distretto: _____________________________________________________________________________________________________________________________________ U.OC./U.O.: ________________________________________________________________________________________________________________________________________________ Direttore (timbro e Firma): ____________________________________________________________ Dirigente Medico (timbro e Firma): _________________________________________________ Tipologia di apparecchiatura o strumento da richiedere in visione: Marca: ______________________________________________________________________________________ N° Serie: ____________________________________________________ Modello: ____________________________________________________________________________________Matricola: __________________________________________________ Accessori: ___________________________________________________________________________________________________________________________________________________ Periodo di visione: Dal __________________________________________________ Al __________________________________________________ Dati società produttrice/distributrice Ragione Sociale: ___________________________________________________________________________ Indirizzo: __________________________________________________ Tel: ___________________________________ Fax: _____________________________________ Referente: ______________________________________________________________ e-mail: ________________________________________________________________________________________________________________________________________________________ Note: __________________________________________________________________________________________________________________________________________________________ ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------Spazio riservato alla U.O.C. Ingegneria Clinica e HTA __________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________ 1