Complaint Case Report 

Date of event *

Product of concern, Product Ref number and Product LOT number or Product Serial number *

Complaint description, what, when? Describe in detail. Any product malfunctions? Any injury? Who/what is injured? If yes, Describe injury. * *

Name *

First

Last

Hospital/Company Name *

Street, zip code, City *

Country *

Phone Number *

Email *

GDPR *

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