ORDER FORM DIZG ALLOGRAFTS

Patient identification (GDPR – no full name or full personal security number)

Order from Clinic (Clinic Name) *

Address *

Postal code & City *

Country *

Phone *

Email *

Att.: Surgeons name *

VAT number (DK- / SE- / NO-…)

Clinic Name (If different from billing address)

Address (If different from billing address)

Postal code & City (If different from billing address)

Country (If different from billing address)

a) Choose product from list

a) Quantity

b) Choose product from list

b) Quantity

c) Choose product from list

c) Quantity

Didn’t you find the DIZG products that you want to order. Fill out with Item no and description

Quantity

Name of the person ordering *

Notes

Order date *

Delivery date – a full day before surgery *

Regulations:
Due to EU regulation allografts are only to be stored for 48 hours at the receipient clinic, if the clinic does not hold a valid tissue bank license Please take this into account when ordering. Choose delivery date just before the date of planned surgery.

Distribution by:
Puredent ApS, Universitetsparken 7, DK 4000 Roskilde phone +45 31311925 | email info@puredent.dk Questions about ordering procedures, products likewise, please contact us directly. Storage at room temperature.

Manufactured by:
DIZG Deutsches Institut für Zell- und Gewebeersatz. distribution@dizg.de phone +49.(0)30.65 76 30.54/67