Customer Complaint Form

Customer Information

Company Name

First Name

Last Name

Phone

Address

City

Select Country

Model Name

Model Number

Lot / Serial Number

Manufacturing Date

Expiry Date

Dave when device was implanted

Date when device was explanted

Date when complaint was identified

Description of complaint

Number of Patients Involved

Has incident been reported?*

Yes - Please indicate below

Optional: Name of Reported Authority

Additional comments / statements

*Required field

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