Alere Triage ® Voluntary Recall Letter

Please complete this form even if you do not have any involved product andFax Back to Technical Service at Fax Number 858-695-7100.Customer Verification FormUrgent Medical Device Recall Notification1. We acknowledge receipt of the Alere San Diego, Inc. notice dated, May 22, 2012 for theProduct Recall Alere Triage ® CardioProfiler ® Panel PN 97100CP, Alere Triage ® CardiacPanel PN 97000HS, Alere Triage ® Profiler SOB Panel PN 97300, Alere Triage ® BNP PN98000XR, and Alere Triage ® D-dimer PN 98100.2. We confirm that all areas where the product could be located have been checked.3. SELECT ALL STATEMENTS THAT APPLYThe following has been verified:We do not have any affected product. If so, indicate zero in the table below.Product was redistributed to another facility.We have the product identified below (please record the product, lot number and quantity)and have disposed of the affected product. (Alere will contact you for replacement orcredit. All replacement or credit will be processed using purchase order: ASD512TRG.)We have the product identified below (please record the product, lot number and quantity)and will continue to use the affected product as we have no alternative testing method.Product Name Part Number Lot Number Kit QuantityDATE*:AUTHORIZED SIGNATURE*:PRINT NAME*:TITLE:DEPARTMENT:INSTITUTION*:ADDRESS*:CITY*: STATE*: PHONE*:POSTAL CODE*:COUNTRY*:EMAIL:To satisfy global requirements for regulatory reporting, please complete and return this form within 10 business days of receipt toTechnical Service at Fax Number +1 858-695-7100.Alere.com 9975 Summers Ridge Road San Diego, California 92121 USA 4 of 4