Customer Complaint/Feed back Form

A. Originator Information

1. First Name :	2. Last Name :	3. Title/Organization :
4. E-Mail Address :	5. Phone Number :	6. Fax Number :
7. Street Address :	8. City :	9. State :
10. Postal Code :	11. Country :

B. Patient Information

1. Date of Birth :

2. Sex :

3. Weight :

C. Product Report

1. Clinical Event and/or Product Problem

2. Date of Event :

3. Describe Event or Problem :

4. Other relevant information to consider, including other preexisting conditions:
(e.g.: allergies, race, pregnancy, smoking, alcohol use, hepatic/renal dysfunction, facility/environment, personnel, equipment, etc.)

5. Other Relevant Information to consider, Including Preexisting Conditions :
(e. g., allergies, race, pregnancy, smoking and alcohol use, hepatic/renal dysfunction, facility personal environment, etc.)

D. Product Information

1. Device Name :	Device Type :	Device Model :	Lot Number :


2. Device Name :	Device Type :	Device Model :	Lot Number :


3. Device Name :	Device Type :	Device Model :	Lot Number :


4. Device Available for Evaluation :	5. If Implanted, Give Date :	6. If Explanted, Give Date :
Yes No

* Please do not return device unless authorized by Implant Direct LLC.
7. Please list additional devices as necessary :
Type here

E. Upload Files

First click on "Browse..." to locate your file. Your file(s) will be uploaded upon submitting the entire form!
Select file 1 : Select file 2 : Select file 3 :	Form Completed On Behalf of Customer By (Internal Use Only):