Request for Medical or Scientific Information

Medical or Scientific Information Request Form

Date*
MM slash DD slash YYYY
Your Name*
First Last
Recognition of Indications for Use*
I recognize that the FDA has cleared Gynesonics' Sonata System for the diagnostic intrauterine imaging and transcervical treatment of symptomatic uterine fibroids, including those associated with heavy menstrual bleeding.
Safety and Effectiveness*
I am aware that safety and effectiveness with regard to fertility and fecundity after the use of the Sonata System, and effectiveness in women with clinically-significant adenomyosis, have not been established.
However, I would like to obtain the following information regarding the Sonata System:*
Unsolicited by Gynesonics Employee or Representative*
I affirm that no Gynesonics employee or representative has promoted, either explicitly or implicitly, the use of Gynesonics' products for purposes that are inconsistent with approved labeling.
Discretion as a Licensed Medical Practitioner*
Any use of Gynesonics' products that is inconsistent with distributed labeling and which I may undertake will be at my sole discretion as a licensed medical practitioner.
Please provide me with any information you have relative to my unsolicited inquiry for information on Gynesonics' Sonata System.
Signature*
Hospital/Practice Information
Hospital or Practice Name*
Mailing Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
A phone number we can use if clarification is required:
An email address we can use for correspondence regarding this request:*

Medical or Scientific Information Request Form

Hospital/Practice Information

REF SOP 04858-007 FRM 04858-021 Rev. C