TTRF – BioXTek

Tissue Tracking Record

This product contains human allograft tissue. In order to maintain allograft records, we request that
your facility print and complete this form and return to BioXtek using email [email protected] or
printout and mail (peelable patient chart labels located on product label).to BioXtek LLC, 316 NE
1st Street, Pompano Beach, FL 33060 or Fax to (754) 946-2055

Tissue Tracking Record

Please fill in the following fields as required by FDA and JCAHO and submit to our HIPAA compliant database for tissue tracking purposes... Thank you

Date of implantation or discard(Required)

Reason for discard

Please provide a reason if this allograft is discarded; otherwise, please fill in all fields

Physician Name:(Required)

First Last

Specialty(Required)

Facility Name(Required)

ASC(Required)

Clinic(Required)

Hospital(Required)

City(Required)

State(Required)

Zip/Postal Code(Required)

Office Telephone Number(Required)

Procedure Description or CPT#(Required)

This field is for validation purposes and should be left unchanged.

Note: In accordance with JCAHO and FDA requirements, it is the responsibility of the healthcare
practitioner to maintain recipient records for the purpose of tracking tissue after implantation. This
tissue tracking record is not a replacement or substitute for the physician’s or facility’s internal tissue
tracking systems.

Tissue Tracking Record

Tissue Tracking Record

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