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(Semi) Automatic External Defibrillator (AED)

aka Public Access Defibrillator (PAD)

MEDICAL AUTHORIZATION and REGISTRATION

The Food and Drug Administration (FDA) considers defibrillators to be prescription devices pursuant to 21 CFR 801.109 and medical authorization is required. The State of Washington provides immunity from civil liability to the physician prescribing an AED pursuant to RCW 70.54.310

Business or Agency Name: *

Physical Address and City where AED placed: *

Mailing Address *

City *

State *

Zip Code *

Contact name *

Contact Business Phone *

Business Fax Number

Contact Email Address *

PHYSICAL LOCATION OF AED IN BUILDING: *

AED Manufacturer: *

AED Model: *

AED Serial Number: *

Date Placed in Service: * +

Date Information Updated: * +

Comments or Additional Information:

If you have multiple AEDs at your location, each AED requires a separate medical authorization.