Customer Complaint/Feed back Form

A. Originator Information Required Fields (1 to 11)

B. Patient Information

1. Date of Birth :		2. Sex :
3. Other Relevant Information to consider, Including Preexisting Conditions : (e. g., allergies, race, pregnancy, smoking and alcohol use, hepatic/renal dysfunction, facility personal environment, etc.) Type here 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.)

C. Product Report

1. Issue / Problem	2. Date of Event :
3. Describe Event or Problem Required Field :

D. Product Information:

For Attachments International products, use #4 and/or #5 below to provide product description. For Biologics products, use #6 below to provide product description. * At least one Lot Number is required to submit this form.
1. Implant Direct Implants :	Device Type :	Device Model :	Lot Number :


2. Implant Direct Prosthetics :	Device Type :	Device Model :	Lot Number :


3. Implant Direct Surgical :	Device Type :	Device Model :	Lot Number :


4. AI Attachment Components :	Device Type :	Device Model :	Lot Number :


5. AI Implant Components :	Device Type :	Device Model :	Lot Number :


6. Biologics :	Device Type :	Device Model :	Lot Number :


7. Device Available for Evaluation Required Field :	8. If Implanted, Give Date :	9. If Explanted, Give Date :
Yes No

For products of Sybron Implant Solutions, use box #9 below to provide product description. * Please do not return device unless authorized by Implant Direct.
10. Please list additional devices as necessary :
Type here

E. Implant Failure/Surgical Information

Was this an immediate extraction case?	Yes No
Was this case immediately loaded?	Yes No
How was the implant placed?
What was the bone quality?
Was bone augmentation material used?	Yes No
What was the insertion torque required to seat the implant?
At implant placement, was there:
Did you use the bone tap?	Yes No
Can the failure be attributed to any of the following?

F. 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 : Digital Radiographs or other materials relevant to this case.	Form Completed On Behalf of Customer By (Internal Use Only):