Medical Device Checkout Consent
Full Name
Device Name
Device ID / Serial Number
Checkout Date
Expected Return Date
Consent Acknowledgement
I acknowledge responsibility for the above device during the checkout period.
I have received instructions for the correct use and care of the device.
I will return the device in the same condition as received, except for normal wear.
I understand that I may be responsible for loss or damage beyond normal use.
Additional Notes
Signature
Date