TERMO DE ANUÊNCIA (AFFIDAVIT)

BR 376 . 11313 . Cruzeiro . São José dos Pinhais - PR . CEP 83010-500 . Fone/Fax: (41) 3299-3400/(41) 3299-3440

Seguindo as Normas PALC, DICQ e RDC 302 será necessário a inclusão de Observação do laudo de não conformidades ou restrição.

TODOS OS DADOS SÃO IMPRESCINDÍVEIS (ALL DATA IS CONSIDERED MANDATORY)

____________________________________________________________________________________________Nome Responsável Técnico (Responsible name):

Nome (Name):

Código do laboratório (Laboratory code):

N⁰ de pedido de pacientes (Request/Sample #): ____________________________________________________________________________________________

Exames (Test to be performed): ________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________

_________________________________________________________________________________________________________________________________________________________________

A(s) amostra(s) para os exame(s) acima, apresentam a(s) seguinte(s) irregularidade(s) (The samples above have the following errors):

_________________________________________________________________________________________________________________________________________________________________

Brasil from any charges that may be imputed to.

_________________________________________________________________________________________________

Cargo (Role): ___________________________________Fone (Telephone #):__________________________________

_______________________,____de________________________de________________________

_________________________________________________________________________________________________________________________________________________________________

Assinatura (Signature): ____________________________________________________________________________________

Responsável Técnico, Carimbo e Conselho de Classe (CRF, CRBM, CRM, CRBIO) - (Responsible and stamp):

CPF (ID #): ___________________________________________

____________________________________________________________________________________________

imputado.