POLARCATH ORDER FORMS - Customer - Boston Scientific

Hospital Name: Date:
Contact Name: Account No.:
Contact Phone: P.O. No.:
Fax Confirmation Phone:
Bill To Address: Ship To Address:
Description Order # UPN Code Quantity Total
2x20x135/0.014 T202013501 M001T2020135010
2x20x150/0.014 T202015001 M001T2020150010
2x40x135/0.014 T204013501 M001T2040135010
2x40x150/0.014 T204015001 M001T2040150010
2x60x135/0.014 T206013501 M001T2060135010
2x60x150/0.014 T206015001 M001T2060150010
2x100x135/0.014 T2010013501 M001T20100135010
2x100x150/0.014 T2010015001 M001T20100150010
2.5x20x135/0.014 T252013501 M001T2520135010
2.5x20x150/0.014 T25201500 M001T2520150010
2.5x40x135/0.014 T254013501 M001T2540135010
2.5x40x150/0.014 T25401500 M001T2540150010
2.5x60x135/0.014 T256013501 M001T2560135010
2.5x60x150/0.014 T25601500 M001T2560150010
2.5x100x135/0.014 T2510013501 M001T25100135010
2.5x100x150/0.014 T2510015001 M001T25100150010
3x20x135/0.014 T302013501 M001T3020135010
3x20x150/0.014 T30201500 M001T3020150010
3x40x135/0.014 T304013501 M001T3040135010
3x40x150/0.014 T30401500 M001T3040150010
3x60x135/0.014 T306013501 M001T3060135010
3x60x150/0.014 T30601500 M001T3060150010
3x100x135/0.014 T3010013501 M001T30100135010
3x100x150/0.014 T3010015001 M001T30100150010
3.5x20x135/0.014 T352013501 M001T3520135010
3.5x20x150/0.014 T35201500 M001T3520150010
3.5x40x135/0.014 T354013501 M001T3540135010
3.5x40x150/0.014 T35401500 M001T3540150010
3.5x60x135/0.014 T356013501 M001T3560135010
3.5x60x150/0.014 T35601500 M001T3560150010
3.5x100x135/0.014 T3510013501 M001T35100135010
3.5x100x150/0.014 T3510015001 M001T35100150010
4x20x135/0.014 T402013501 M001T4020135010
4x20x150/0.014 T40201500 M001T4020150010
4x40x135/0.014 T404013501 M001T4040135010
4x40x150/0.014 T40401500 M001T4040150010
4x60x135/0.014 T406013501 M001T4060135010
4x60x150/0.014 T40601500 M001T4060150010
4x100x135/0.014 T4010013501 M001T40100135010
4x100x150/0.014 T4010015001 M001T40100150010
5x20x135/0.014 T502013501 M001T5020135010
5x40x135/0.014 T504013501 M001T5040135010
5x60x135/0.014 T506013501 M001T5060135010
6x20x135/0.014 T602013501 M001T6020135010
6x40x135/0.014 T604013501 M001T6040135010
6x60x135/0.014 T606013501 M001T6060135010
Inflation Unit PCIU4 M001PCIU400000
Nitrous Oxide Cartridge (Box)* NC2 M001NC20000001
Power Module System** BATR1110 M001BATR111000
Rechargeable Battery REBAT01 M001REBAT01000
Battery Charger Unit BATCHGUS1 M001BATCHG100
Battery Mount BATMT01 M001BATMT0100
Territory Manager:
PolarCath Peripheral Dilatation System 0.014" Order Form
*10 Nitrous Oxide Cartridges to a Box.
**Includes Two Rechargeable Batteries, Battery Mount and Battery Charger Unit.

Boston Scientific Corporation
One Boston Scientific Place
Natick, MA 01760-1537
www.bostonscientific.com
To order product or for more
information, contact customer
service at 1.888.272.1001
or fax 1.888.272.9444
© 2006 by Boston Scientific
Corporation or its affiliates.
All rights reserved.
USPV4402.147.0

Hospital Name: Date:
Contact Name: Account No.:
Contact Phone: P.O. No.:
Fax Confirmation Phone:
Bill To Address: Ship To Address:
Description Order # UPN Code Quantity Cost Total
4x20x80/0.035 P42008001 M001P420080010
4x20x120/0.035 P42012001 M001P420120010
4x40x80/0.035 P44008001 M001P440080010
4x40x120/0.035 P44012001 M001P440120010
4x60x80/0.035 P46008001 M001P460080010
4x60x120/0.035 P46012001 M001P460120010
4x80x80/0.035 P48008001 M001P480080010
4x80x120/0.035 P48012001 M001P480120010
4x100x80/0.035 P410008001 M001P4100080010
4x100x120/0.035 P410012001 M001P4100120010
5x20x80/0.035 P52008001 M001P520080010
5x20x120/0.035 P52012001 M001P520120010
5x40x80/0.035 P54008001 M001P540080010
5x40x120/0.035 P54012001 M001P540120010
5x60x80/0.035 P56008001 M001P560080010
5x60x120/0.035 P56012001 M001P560120010
5x80x80/0.035 P58008001 M001P580080010
5x80x120/0.035 P58012001 M001P580120010
5x100x80/0.035 P510008001 M001P5100080010
5x100x120/0.035 P510012001 M001P5100120010
6x20x80/0.035 P62008001 M001P620080010
6x20x120/0.035 P62012001 M001P620120010
6x40x80/0.035 P64008001 M001P640080010
6x40x120/0.035 P64012001 M001P640120010
6x60x80/0.035 P66008001 M001P660080010
6x60x120/0.035 P66012001 M001P660120010
6x80x80/0.035 P68008001 M001P680080010
6x80x120/0.035 P68012001 M001P680120010
6x100x80/0.035 P610008001 M001P6100080010
6x100x120/0.035 P610012001 M001P6100120010
7x20x80/0.035 P72008001 M001P720080010
7x20x120/0.035 P72012001 M001P720120010
7x40x80/0.035 P74008001 M001P740080010
7x40x120/0.035 P74012001 M001P740120010
7x60x80/0.035 P76008001 M001P760080010
7x60x120/0.035 P76012001 M001P760120010
7x80x80/0.035 P78008001 M001P780080010
7x80x120/0.035 P78012001 M001P780120010
8x20x80/0.035 P82008001 M001P820080010
8x20x120/0.035 P82012001 M001P820120010
8x40x80/0.035 P84008001 M001P840080010
8x40x120/0.035 P84012001 M001P840120010
Inflation Unit PCIU4 M001PCIU400000
Nitrous Oxide Cartridge (Box)* NC2 M001NC20000001
Power Module System** BATR1110 M001BATR111000
Rechargeable Battery REBAT01 M001REBAT01000
Battery Charger Unit BATCHGUS1 M001BATCHG100
Battery Mount BATMT01 M001BATMT0100
Territory Manager:
PolarCath Peripheral Dilatation System 0.035" Order Form
*10 Nitrous Oxide Cartridges to a Box.
**Includes Two Rechargeable Batteries, Battery Mount and Battery Charger Unit.

Boston Scientific Corporation
One Boston Scientific Place
Natick, MA 01760-1537
www.bostonscientific.com
To order product or for more
information, contact customer
service at 1.888.272.1001
or fax 1.888.272.9444
© 2006 by Boston Scientific
Corporation or its affiliates.
All rights reserved.

Hospital Name: Date:
Contact Name: Account No.:
Contact Phone: P.O. No.:
Fax Confirmation Phone:
Bill To Address: Ship To Address:
Description Order # UPN Code Quantity Cost Total
2x100x135/0.014 T2010013501 M001T20100135010
2x100x150/0.014 T2010015001 M001T20100150010
2.5x100x135/0.014 T2510013501 M001T25100135010
2.5x100x150/0.014 T2510015001 M001T25100150010
3x100x135/0.014 T3010013501 M001T30100135010
3x100x150/0.014 T3010015001 M001T30100150010
3.5x100x135/0.014 T3510013501 M001T35100135010
3.5x100x150/0.014 T3510015001 M001T35100150010
4x100x135/0.014 T4010013501 M001T40100135010
4x100x150/0.014 T4010015001 M001T40100150010
4x100x80/0.035 P410008001 M001P4100080010
4x100x120/0.035 P410012001 M001P4100120010
5x100x80/0.035 P510008001 M001P5100080010
5x100x120/0.035 P510012001 M001P5100120010
6x100x80/0.035 P610008001 M001P6100080010
6x100x120/0.035 P610012001 M001P6100120010
Inflation Unit PCIU4 M001PCIU400000
Nitrous Oxide Cartridge (Box)* NC2 M001NC20000001
Power Module System** BATR1110 M001BATR111000
Rechargeable Battery REBAT01 M001REBAT01000
Battery Charger Unit BATCHGUS1 M001BATCHG100
Battery Mount BATMT01 M001BATMT0100
Territory Manager:
PolarCath Peripheral Dilatation System 100mm Order Form
*10 Nitrous Oxide Cartridges to a Box.
**Includes Two Rechargeable Batteries, Battery Mount and Battery Charger Unit.
Boston Scientific Corporation
One Boston Scientific Place
Natick, MA 01760-1537
www.bostonscientific.com
To order product or for more
information, contact customer
service at 1.888.272.1001
or fax 1.888.272.9444
© 2006 by Boston Scientific
Corporation or its affiliates.
All rights reserved.

PolarCath Peripheral Dilatation System
Order Number UPN Code
NEW 100MM CATHETERS
Sheath Size (F)
Compatibility
Guidewire
Compatibility
Balloon
Diameter Balloon Length Catheter Length
T2010013501 M001T20100135010 5fr 0.014" 2mm 100mm 135cm
T2010015001 M001T20100150010 5fr 0.014" 2mm 100mm 150cm
T2510013501 M001T25100135010 5fr 0.014" 2.5mm 100mm 135cm
T2510015001 M001T25100150010 5fr 0.014" 2.5mm 100mm 150cm
T3010013501 M001T30100135010 5fr 0.014" 3mm 100mm 135cm
T3010015001 M001T30100150010 5fr 0.014" 3mm 100mm 150cm
T3510013501 M001T35100135010 5fr 0.014" 3.5mm 100mm 135cm
T3510015001 M001T35100150010 5fr 0.014" 3.5mm 100mm 150cm
T4010013501 M001T40100135010 5fr 0.014" 4mm 100mm 135cm
T4010015001 M001T40100150010 5fr 0.014" 4mm 100mm 150cm
P410008001 M001P4100080010 6fr 0.035" 4mm 100mm 80cm
P410012001 M001P4100120010 6fr 0.035" 4mm 100mm 120cm
P510008001 M001P5100080010 6fr 0.035" 5mm 100mm 80cm
P510012001 M001P5100120010 6fr 0.035" 5mm 100mm 120cm
P610008001 M001P6100080010 7fr 0.035" 6mm 100mm 80cm
P610012001 M001P6100120010 7fr 0.035" 6mm 100mm 120cm
Boston Scientific Corporation
One Boston Scientific Place
Natick, MA 01760-1537
www.bostonscientific.com
© 2006 by Boston Scientific
Corporation or its affiliates.
All rights reserved.

PolarCath Peripheral Dilatation System
CATHETERS
Order Number UPN Code
Sheath Size (F)
Compatibility
Guidewire
Compatibility
Balloon
Diameter
Balloon
Length
Catheter
Length
T202013501 M001T2020135010 5F 0.014" 2mm 20mm 135cm
T202015001 M001T2020150010 5F 0.014" 2mm 20mm 150cm
T204013501 M001T2040135010 5F 0.014" 2mm 40mm 135cm
T204015001 M001T2040150010 5F 0.014" 2mm 40mm 150cm
T206013501 M001T2060135010 5F 0.014" 2mm 60mm 135cm
T206015001 M001T2060150010 5F 0.014" 2mm 60mm 150cm
T2010013501 M001T20100135010 5F 0.014" 2mm 100mm 135cm
T2010015001 M001T20100150010 5F 0.014" 2mm 100mm 150cm
T252013501 M001T2520135010 5F 0.014” 2.5mm 20mm 135cm
T25201500 M001T2520150010 5F 0.014” 2.5mm 20mm 150cm
T254013501 M001T2540135010 5F 0.014” 2.5mm 40mm 135cm
T25401500 M001T2540150010 5F 0.014" 2.5mm 40mm 150cm
T256013501 M001T2560135010 5F 0.014” 2.5mm 60mm 135cm
T25601500 M001T2560150010 5F 0.014" 2.5mm 60mm 150cm
T2510013501 M001T25100135010 5F 0.014” 2.5mm 100mm 135cm
T2510015001 M001T25100150010 5F 0.014" 2.5mm 100mm 150cm
T302013501 M001T3020135010 5F 0.014” 3mm 20mm 135cm
T30201500 M001T3020150010 5F 0.014” 3mm 20mm 150cm
T304013501 M001T3040135010 5F 0.014” 3mm 40mm 135cm
T30401500 M001T3040150010 5F 0.014” 3mm 40mm 150cm
T306013501 M001T3060135010 5F 0.014” 3mm 60mm 135cm
T30601500 M001T3060150010 5F 0.014” 3mm 60mm 150cm
T3010013501 M001T30100135010 5F 0.014” 3mm 100mm 135cm
T3010015001 M001T30100150010 5F 0.014” 3mm 100mm 150cm
T352013501 M001T3520135010 5F 0.014” 3.5mm 20mm 135cm
T35201500 M001T3520150010 5F 0.014" 3.5mm 20mm 150cm
T354013501 M001T3540135010 5F 0.014” 3.5mm 40mm 135cm
T35401500 M001T3540150010 5F 0.014" 3.5mm 40mm 150cm
T356013501 M001T3560135010 5F 0.014” 3.5mm 60mm 135cm
T35401500 M001T3540150010 5F 0.014" 3.5mm 60mm 150cm
T3510013501 M001T35100135010 5F 0.014” 3.5mm 100mm 135cm
T3510015001 M001T35100150010 5F 0.014" 3.5mm 100mm 150cm
T402013501 M001T4020135010 5F 0.014” 4mm 20mm 135cm
T40201500 M001T4020150010 5F 0.014" 4mm 20mm 150cm
T404013501 M001T4040135010 5F 0.014” 4mm 40mm 135cm
T40401500 M001T4040150010 5F 0.014" 4mm 40mm 150cm
T406013501 M001T4060135010 5F 0.014” 4mm 60mm 135cm
T40601500 M001T4060150010 5F 0.014" 4mm 60mm 150cm
T4010013501 M001T40100135010 5F 0.014” 4mm 100mm 135cm
T4010015001 M001T40100150010 5F 0.014" 4mm 100mm 150cm
T502013501 M001T5020135010 5.5F 0.014" 5mm 20mm 135cm
T504013501 M001T5040135010 5.5F 0.014" 5mm 40mm 135cm
T506013501 M001T5060135010 6F 0.014" 5mm 60mm 135cm
T602013501 M001T6020135010 6F 0.014" 6mm 20mm 135cm
T604013501 M001T6040135010 6F 0.014" 6mm 40mm 135cm
T606013501 M001T6060135010 6F 0.014" 6mm 60mm 135cm
P42008001 M001P420080010 6F 0.035” 4mm 20mm 80cm
P42012001 M001P420120010 6F 0.035” 4mm 20mm 120cm
P44008001 M001P440080010 6F 0.035” 4mm 40mm 80cm
P44012001 M001P440120010 6F 0.035” 4mm 40mm 120cm
P46008001 M001P460080010 6F 0.035” 4mm 60mm 80cm
P46012001 M001P460120010 6F 0.035” 4mm 60mm 120cm
P48008001 M001P480080010 6F 0.035” 4mm 80mm 80cm
P48012001 M001P480120010 6F 0.035” 4mm 80mm 120cm
P410008001 M001P4100080010 6F 0.035” 4mm 100mm 80cm
P410012001 M001P4100120010 6F 0.035” 4mm 100mm 120cm
P52008001 M001P520080010 6F 0.035” 5mm 20mm 80cm
P52012001 M001P520120010 6F 0.035” 5mm 20mm 120cm
P54008001 M001P540080010 6F 0.035” 5mm 40mm 80cm
P54012001 M001P540120010 6F 0.035” 5mm 40mm 120cm
P56008001 M001P560080010 6F 0.035” 5mm 60mm 80cm
P56012001 M001P560120010 6F 0.035” 5mm 60mm 120cm
P58008001 M001P580080010 6F 0.035” 5mm 80mm 80cm
P58012001 M001P580120010 6F 0.035” 5mm 80mm 120cm
P510008001 M001P5100080010 6F 0.035” 5mm 100mm 80cm
P510012001 M001P5100120010 6F 0.035” 5mm 100mm 120cm
P62008001 M001P620080010 7F 0.035” 6mm 20mm 80cm
P62012001 M001P620120010 7F 0.035” 6mm 20mm 120cm
P64008001 M001P640080010 7F 0.035” 6mm 40mm 80cm
P64012001 M001P640120010 7F 0.035” 6mm 40mm 120cm
P66008001 M001P660080010 7F 0.035” 6mm 60mm 80cm
P66012001 M001P660120010 7F 0.035” 6mm 60mm 120cm
P68008001 M001P680080010 7F 0.035” 6mm 80mm 80cm

PolarCath Peripheral Dilatation System - Continued
CATHETERS
Order Number UPN Code
Sheath Size (F)
Compatibility
Guidewire
Compatibility
Balloon
Diameter
Balloon
Length
Catheter
Length
P68012001 M001P680120010 7F 0.035” 6mm 80mm 120cm
P610008001 M001P6100080010 7F 0.035” 6mm 100mm 80cm
P610012001 M001P6100120010 7F 0.035” 6mm 100mm 120cm
P72008001 M001P720080010 7F 0.035” 7mm 20mm 80cm
P72012001 M001P720120010 7F 0.035” 7mm 20mm 120cm
P74008001 M001P740080010 7F 0.035” 7mm 40mm 80cm
P74012001 M001P740120010 7F 0.035” 7mm 40mm 120cm
P76008001 M001P760080010 7F 0.035” 7mm 60mm 80cm
P76012001 M001P760120010 7F 0.035” 7mm 60mm 120cm
P78008001 M001P780080010 7F 0.035” 7mm 80mm 80cm
P78012001 M001P780120010 7F 0.035” 7mm 80mm 120cm
P82008001 M001P820080010 8F 0.035" 8mm 20mm 80cm
P82012001 M001P820120010 8F 0.035" 8mm 20mm 120cm
P84008001 M001P840080010 8F 0.035" 8mm 40mm 80cm
P84012001 M001P840120010 8F 0.035" 8mm 40mm 120cm
ACCESSORIES
Description Quantity Order Number
UPN Code
Inflation Unit 1 PCIU4
M001PCIU400000
Nitrous Oxide Cartridge*
10 NC2 M001NC20000001
Power Module System**
1 BATR1110 M001BATR111000
Rechargeable Battery
1 REBAT01 M001REBAT01000
Battery Charger Unit
1 BATCHGUS1 M001BATCHG100
Battery Mount
1 BATMT01 M001BATMT0100
*10 Nitrous Oxide Cartridges to a Box.
**Includes Two Rechargeable Batteries, Battery Mount and Battery Charger Unit.
INDICATIONS FOR USE
The PolarCath Peripheral Dilatation System is indicated to dilate stenosis in the peripheral vasculature (iliac, femoral, popliteal, infrapopliteal, renal and
subclavian arteries) and for the treatment of obstructive lesions of Polytetrafluoroethylene (PTFE) access grafts or native arteriovenous dialysis fistulae. The
PolarCath Peripheral Dilatation system is also indicated for post-deployed stent expansion of self-expanding peripheral vascular stents.
WARNINGS
� Use of this device in coronary or carotid arteries has not been evaluated.
� Use of this device for stent delivery or stent expansion has not been evaluated.
� Use of this device for non-PTFE access grafts has not been evaluated.
� Do not move the catheter while the warming light is illuminated.
� Treatment at a 1:1 balloon diameter to reference artery ratio is recommended.
� Inflate the PolarCath System catheter only with the PolarCath System PolarCath Inflation Unit. Never use contrast and/or saline to inflate the balloon.
� Do not submerge proximal end of catheter or PolarCath Inflation Unit in water or saline solution.
� The catheter should be deployed while using high quality fluoroscopy. Do not advance or retract the catheter unless the balloon is fully deflated under
vacuum. Do not place the PolarCath Inflation Unit in direct ionizing radiation, e.g., do not place the PolarCath Inflation Unit under the fluoroscopy head.
� Handle the nitrous oxide cartridges only by the plastic cap.
� Handle only the plug and never the connections that are inserted into the PolarCath Inflation Unit.
PRECAUTIONS
Only PTFE Arteriovenous (AV) graft material has been tested for compatibility with the PolarCath System.
The use of any sheath having a flat metal coil support must be used with caution since exposed metal coils can potentially puncture the balloon.
Do not reinsert the catheter once it has been removed from the sheath.
POTENTIAL ADVERSE EVENTS
Possible adverse events include but are not limited to the following:
� Allergic reaction to contrast media � Pyrogenic reaction
� Arteriovenous Fistulae
� Restenosis of the dilated vessel
� Death
� Sepsis/infection
� Embolism
� Thrombus
� Gas embolism
� Total occlusion
� Hemmorrhage/hematoma
� Vessel dissection
� Pain and tenderness � Vessel perforation
� Pseudoaneurysm formation
Prior to use, please see the full “Instructions for Use” supplied with the PolarCath Peripheral Dilatation Catheter.
Caution: Federal Law (USA) restricts this device to sales by or on the order of a physician.
Boston Scientific Corporation
One Boston Scientific Place
Natick, MA 01760-1537
www.bostonscientific.com
© 2006 by Boston Scientific
Corporation or its affiliates.
All rights reserved.
USPV4402.147.0