EVERSIGHT SERVICES
SURGEON FORMS
TRACKING METHOD AGREEMENT
In compliance with FDA Final Rule 21CFR Part 1271, Current Good Tissue Practice for
Human Cell, Tissue and Cellular and Tissue-Based Product Establishments, Inspection and
Enforcement, I have been informed of the requirements of §1271.290, Tracking.
I have received a copy of this section as well as the Eversight policy and procedure
for recipient information tracking (M1.511, Recipient Information Tracking Procedure).
I agree to participate in Eversight's tracking methods outlined in the above policy and
procedure and will take all necessary steps to ensure compliance with these requirements.
Name (please print):___________________________________________________________________
Signature:_____________________________________________________________________________
Date:_______________________________________
*Revised January 30, 2017
Tissue Placement: (866) 900-8119 • Fax (734) 780-2730 • [email protected]