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Name

Phone

E-mail

Subject

Complaint details:

Product Reference Code code *:

Product Lot code *:

When has the event occurred *: Before, during or after use of the device?

Description of the problem occurred *:

What were the consequences for the patient due to the adverse event? *

What has been done by the end user (i.e. Doctor, nurse, etc) to solve the the problem? *

Patient information (the case): gender, age, known medical history & clinical condition

Please note that any photos and/or videos that would help in the investigation of the root cause will stil be highly appreciated.

* Mandatory fields