In compliance with ruling 648/2004/CE, we can provide a medical information sheet on our products upon request. Medical staff must treat information given in the sheet as confidential and can use it only for medical purposes. To ensure correct registration and handling of your request, please print this form and fax it or post it to us.

> Details of person making the request:
Name:
Position:
Registration No. INAMI http://inami.fgov.be/

> Product details:
Product name:
EAN code (the number underneath the bar code):
Packaging:

> Reason for the request: