Warranty formulary

2-year warranty on CoaguChek^® INRange manufactured by Roche Diagnostics

To validate the 2-year warranty for your CoaguChek^® INRange meter in Canada, complete and submit this warranty formulary.

Your CoaguChek^® INRange

Fields marked with * must be completed.

CoaguChek^® INRange serial #*:

The serial number is on the back of the meter above the barcode.

Date of purchase*:

First name*:

Last name*:

Date of birth*:

Is this meter for your own use to do INR self-testing?*

Yes

No

If no, how will you use this meter?

Are you a healthcare professional?*

Yes

No

If yes, please indicate profession

Contact

Street*:

Unit:

City*:

Postal code*:

Phone*:

Email*:

Language*:

English

French

Patient declarations

I am aware that a prescription is required for a patient to have INR testing done with the CoaguChek^® INRange system.

I am aware of the test limitations and interferences of the CoaguChek^® INRange system (refer to the Product Insert found in the CoaguChek^® INRange test strip box).

I can use the CoaguChek^® INRange meter correctly to obtain a coagulation result.

If I have any questions, I can obtain training information available on the website (www.coaguchek.ca) and at the Coagulation Info-Line at 1-877-426-2482.

I would like to receive communications from Roche such as CoaguChek^® product news and promotions

The CoaguChek^® auto control system from Roche Diagnostics is guaranteed against all defects of functioning, manufacturing, or parts for a period of two years, beginning on the date of purchase.

Liability under this warranty extends only to the repair or replacement of defective parts or materials or to the replacement of the system purchased to the exclusion of all other claims, demands, actions, and remedies even if the defect, damage, or loss has been caused by negligence or other fault of Roche Diagnostics.

The warranty guarantees replacement of the system in the event of damage or any system malfunction that cannot be solved by means other than replacement of the components. This warranty replaces and supersedes any other warranty, whether expressed, implied, contractual, extra-contractual or statutory, respecting the named system, including but not limited to any implied warranty of fitness for a particular purpose.

This warranty shall not apply to a Roche Diagnostics system not installed and/or used according to the instructions or specifications thereof, or to a Roche Diagnostics system damaged by accident or subjected to alteration, misuse, tampering, abuse, and/or repair or attempted repair by someone other than Roche Diagnostics or an authorized agent.

In no event shall Roche Diagnostics be liable for any incidental, indirect, special, or consequential damages whatsoever, including but not limited to any personal or material damages or loss of use, revenue, or profit, even if the defect, damage, or loss is caused by the negligence or other fault of Roche Diagnostics.

This warranty is granted only to the first purchaser for use of the system and is not transferable.

The warranty is valid only if the name of the monitor and its serial number, date of purchase, and other requested information are entered on the attached Warranty card, which must be returned to Roche Diagnostics within thirty (30) days of purchase.

The warranty period is not affected by any claim made under the warranty.

If you have a claim under warranty, please call the following toll-free number: 1-877-426-2482

Roche Diagnostics
Division of Hoffmann-La Roche Ltd
201 Armand-Frappier Blvd. Laval, Quebec H7V 4A2

Warranty formulary

Your CoaguChek® INRange

Contact

Patient declarations

Your CoaguChek^® INRange