3. Sample of the Product and Samples of the Packaging As general rule we require one sample of the product and a sample of the packaging and patient information leaflet/instructions for use if the product has one. If you are applying for a range of products you can send one sample of one size and then provide samples of the packaging/packaging labels for all of the other sizes in the range. For example, if you are applying for a range of dressings in various sizes you need only provide a sample of one of the sizes. If you are providing packaging samples bearing the codes, please make sure that the codes match the codes included in the DT1Form and/or documentation. Specific advice regarding sample requirements is available if needed. I confirm that the information provided in this DT1 Form is correct at the time of completion and that I will inform NHS Prescription Services of any changes that occur during the application process and subsequent to a successful listing. I am also aware that this application will not be processed if any of the above is not provided. Signed: Print Name: ……………………………………….. Date: For more information on the application procedure, please see Drug Tariff Part IX Guidance to Manufacturers and Suppliers of Medical Devices available at: or e-mail us on
3. Sample of the Product and Samples of the Packaging As general rule we require one sample of the product and a sample of the packaging and patient information leaflet/instructions for use if the product has one. If you are applying for a range of products you can send one sample of one size and then provide samples of the packaging/packaging labels for all of the other sizes in the range. For example, if you are applying for a range of dressings in various sizes you need only provide a sample of one of the sizes. If you are providing packaging samples bearing the codes, please make sure that the codes match the codes included in the DT1Form and/or documentation. Specific advice regarding sample requirements is available if needed. I confirm that the information provided in this DT1 Form is correct at the time of completion and that I will inform NHS Prescription Services of any changes that occur during the application process and subsequent to a successful listing. I am also aware that this application will not be processed if any of the above is not provided. Signed: ……………………………………….. Print Name: Date: For more information on the application procedure, please see Drug Tariff Part IX Guidance to Manufacturers and Suppliers of Medical Devices available at: or e-mail us on
DT1B%20Class%20III%20Medical%20Devices.docx