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LAVA^TM is a registered trademark of Sirtex SIR-Spheres Pty Ltd.

By submitting this Credit Card Payment Form (“Form”), the Customer gives Sirtex Medical, Inc. (“Sirtex”) permission to debit Customer’s account for the amount indicated on or after the indicated date. Such submission constitutes Customer’s acceptance of Sirtex’s Order and Cancellation Policy, a copy of which is available upon request, as well as certification that all required steps (i.e. insurance approval, lab work, etc.) have been performed prior to ordering and that Customer is appropriately licensed to handle the products ordered herein.

Customer certifies they are an authorized user of this credit card and this payment will not be disputed with the applicable credit card company provided the transaction corresponds to the terms indicated herein. If for any reason payment cannot be completed via the credit card provided on this Form, Customer shall be liable for any outstanding balances due.

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.