Renovo Bioscience Tracking Record

FACILITY INFORMATION

HOSPITAL/ SURGICAL CENTER/ CLINIC NAME

CITY

STATE

ZIP

NAME OF PHYCSICIAN/CLINICIAN

NAME OF PERSON PROVIDING DATA

PATIENT FIRST NAME

PATIENT LAST NAME

PATIENT ID#

DATE OF BIRTH

Only record one patient and one procedure per form

NAME OF PRODUCT

Intra-Site™ Connective Tissue Allograft

PRODUCT LOT #

TYPE OF PROCEDURE

DATE OF PROCEDURE

Other Comments

I confirm that all information is verifiable in the patient's medical chart