Cancel Order Form

Thank you for using the Sirtex Online Cancellation Form. Please complete the fields below to complete your request. After your cancellation is submitted, you will receive a confirmation of receipt from Customer Service. If you have any questions, please email csusa@sirtex.com or call us on one of our numbers listed on our Contact page.

Cancellation Request

Hospital Name *

Account Number *

Address *

City *

State *

Zipcode *

Contact Name *

Contact Phone *

Contact Email *

Additional Confirmation Recipient(s)

Delivery Date *

Sales order #

PO# to Cancel

QUANTITY TO CANCEL

Item Number	Item	Description
SLLES182	LAVA Liquid Embolic System	2 mL, 18
SLLES186	LAVA Liquid Embolic System	6 mL, 18
SLLES342	LAVA Liquid Embolic System	2 mL, 34
SLLES346	LAVA Liquid Embolic System	6 mL, 34
SLLESMK2	LAVA Liquid Embolic System	LAVA 2 mL Mixing Kit
SLLESMK6	LAVA Liquid Embolic System	LAVA 6 mL Mixing Kit

Reason for Cancellation*

Signature *

Date *

* mandatory field

Caution: U.S. federal law restricts the sale, distribution, and use of this product to physicians or as prescribed by a physician. This device should be used only by physicians with a thorough understanding of angiography and percutaneous interventional procedures, and the physician would have successfully completed training. Indications for Use: LAVA® LES is indicated for embolization of arterial hemorrhage in the peripheral vasculature. Potential Complications: Potential adverse effects (e.g., complications) associated with the use of the device include: Non-target embolization, Ischemia or infarction of the target territory, Allergic reactions to device components, Catheter breakage, Catheter entrapment, Inadvertent embolization of a non-target vessel or territory, Embolization of device components, Access site hematoma or ecchymosis, Access site false aneurysm, Pain at access site, Arterial dissection, Mural thrombus formation, Vessel perforation, Hemorrhage, Recanalization, Vessel perforation, Arteriovenous fistula, Distal atheroembolism, Infection, Sepsis, Serous drainage, Lymphorrhea, Leg edema, Leg pain, and Back pain. Consult the Instructions for Use for a complete listing of indications, contraindications, potential complications, warnings, and precautions.