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Complaint Case Report
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Date of event
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Product of concern, Product Ref number and Product LOT number or Product Serial number
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Complaint description, what, when? Describe in detail. Any product malfunctions? Any injury? Who/what is injured? If yes, Describe injury. *
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Name
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First
Last
Hospital/Company Name
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Street, zip code, City
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Country
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Phone Number
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Email
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GDPR
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