Charitable Product Donations Form

Host country for Mission Trip:
Date(s) of Mission:
Letter from Ministry of Health (MOH) will be provided to Artivion documenting approval to provide devices/tissues for this mission trip (Yes or No)?
Please upload the letter from Ministry of Health (MOH):

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Artivion may approve in‑kind product donations only for use in jurisdictions where the donated product is legally registered and approved for distribution. If the product is not registered or approved in the recipient’s jurisdiction, the requester is responsible for obtaining all necessary authorizations from the applicable Ministry of Health or regulatory authority before Artivion may approve the request.
Local Hospital (Where surgeries will take place):
Hospital Name
Address

Street Address

Street Address Line 2

CityState

Zip CodeCountry
Main Contact Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
If there is another party that is associated with the mission trip, please include contact information for them:
Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

On-X Heart Valves:

Homografts:

Chord-X (5-pack box):

PhotoFix:

BioGlue (5-pack box):

Other:

Please note: Artivion requests submission of applications at least 90 days before the requested funding decision date or event start date. Applications submitted with less than 90 days before the requested funding decision date may be denied.
Signature

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