TERMO DE ANUÊNCIA (AFFIDAVIT) BR 376 . 11313 . Cruzeiro . São José dos Pinhais - PR . CEP 83010-500 . Fone/Fax: (41) 3299-3400/(41) 3299-3440 Seguindo as Normas PALC, DICQ e RDC 302 será necessário a inclusão de Observação do laudo de não conformidades ou restrição. TODOS OS DADOS SÃO IMPRESCINDÍVEIS (ALL DATA IS CONSIDERED MANDATORY) ____________________________________________________________________________________________ Nome Responsável Técnico (Responsible name): Nome (Name): Código do laboratório (Laboratory code): N⁰ de pedido de pacientes (Request/Sample #): ____________________________________________________________________________________________ Exames (Test to be performed): ________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________ A(s) amostra(s) para os exame(s) acima, apresentam a(s) seguinte(s) irregularidade(s) (The samples above have the following errors): _________________________________________________________________________________________________________________________________________________________________ Brasil from any charges that may be imputed to. _________________________________________________________________________________________________ Cargo (Role): ___________________________________Fone (Telephone #):__________________________________ _______________________,____de________________________de________________________ _________________________________________________________________________________________________________________________________________________________________ Assinatura (Signature): ____________________________________________________________________________________ Responsável Técnico, Carimbo e Conselho de Classe (CRF, CRBM, CRM, CRBIO) - (Responsible and stamp): CPF (ID #): ___________________________________________ ____________________________________________________________________________________________ imputado.
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TERMO DE ANUÊNCIA (AFFIDAVIT)
BR 376 . 11313 . Cruzeiro . São José dos Pinhais - PR . CEP 83010-500 . Fone/Fax: (41) 3299-3400/(41) 3299-3440
Seguindo as Normas PALC, DICQ e RDC 302 será necessário a inclusão de Observação do laudo de não conformidades ou restrição.
TODOS OS DADOS SÃO IMPRESCINDÍVEIS (ALL DATA IS CONSIDERED MANDATORY)
____________________________________________________________________________________________Nome Responsável Técnico (Responsible name):
Nome (Name):
Código do laboratório (Laboratory code):
N⁰ de pedido de pacientes (Request/Sample #): ____________________________________________________________________________________________
Exames (Test to be performed): ________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________________________________________________
A(s) amostra(s) para os exame(s) acima, apresentam a(s) seguinte(s) irregularidade(s) (The samples above have the following errors):
_________________________________________________________________________________________________________________________________________________________________
Brasil from any charges that may be imputed to.
_________________________________________________________________________________________________
Cargo (Role): ___________________________________Fone (Telephone #):__________________________________
_______________________,____de________________________de________________________
_________________________________________________________________________________________________________________________________________________________________
Assinatura (Signature): ____________________________________________________________________________________
Responsável Técnico, Carimbo e Conselho de Classe (CRF, CRBM, CRM, CRBIO) - (Responsible and stamp):
CPF (ID #): ___________________________________________
____________________________________________________________________________________________
imputado.
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