Philips Healthcare

Medical Device Installation Record (MDIR)

Customer Name: Sales Order Number:

Product/System
Address:
Description:
City, Province/State, Product/System Model
Postal/Zip Code: Number:
Telephone: Serial Number:
Site ID:

Customer Installation & Acceptance

The equipment for the order listed above has been installed at customers designated location, plus electronically and mechanically
tested to be performing in substantial compliance with Philips published specifications. Any minor deficiencies are noted below. Philips
will remain responsible for any undelivered contractually agreed to items. Signature below indicates customer acceptance and that the
products are now available for first patient use.

System Acceptance Date:

(Date)
Customer Representative:

(Print Name) (Title)

(Signature) (Date)

Philips Representative:
(Print Name) (Title)

(Signature) (Date)

Additional Order Information:

The Philips system is installed and accepted except for the functionality listed below:

Undelivered Philips products or services:

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