Complaints

Salutation

Salutation Title

Name*

First name Last name

Clinic / Practice / Company*

Address*

Street, Number City ZIP / Postal Code Country

Phone

Email*

Item no.*

LOT no.

Serial no.

When was the complaint determined?

Date

Time

Where did the damage occur?*

In / on the Patient
During use e.g. operation, diagnose, treatment (Please specify date and exact use below)
Outside of the OR
Somewhere else (Please specify exact place below)
Not known

Did this incident injure the patient, the user, or another person?*

Information about the patient (if damaged)

Age Size Weight Gender

Clinical condition

Description of complaint / damage*

What intervention was taken by hospital or others?*

Data Protection*

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Form for complaint