NeuRx Recall Registration | Synapse Biomedical Inc.

REF: 23-0021 (EPG), SN: 1900-2017

Comments
This field is for validation purposes and should be left unchanged.
Patient Name*
First Last
Email Address*
Phone Number*
Do you have access to backup ventilation?*
- Yes
- No
- Not Applicable
Do you have a cardiac pacemaker?*
- Yes
- No
Preferred Method Of Contact*
- Email
- Phone
Address*
NOTE: Please no P.O. boxes

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Serial Number of First Device*
See example in photo below
Serial Number of Second Device*
See example in photo below. (If not applicable, enter "n/a")
By submitting this form, you give permission to Synapse Biomedical to contact you regarding this recall