Return Request Form - Surgical fail

1
How to return Surgical fail product(s)

Please read this instruction and follow the steps carefully:

1. Complete the return request form and print out the emailed PDF return request form.

2. Please fill out all required information such as patient details and product lot number as it is mandatory for regulatory compliance.

3. Surgical fail is not applicable to the superstructure such as prosthetics and restoration components.

4. Decontaminate the product(s) :

- All return products from the patient must be cleaned, decontaminated and sealed in the sterile pouch. The indicator on the pouch should show that it has been finished a sterilisation cycle.

5. All returns must be accompanied with printed return request form and ship it to the return department address.

- Product(s) can only be returned to our return department via courier or trackable Auspost service.

- Do not give any product(s) to your sales representative for return.

- Return shipping cost must be subjected to customer responsibility.

- If product(s) is received and deemed unsuitable for handling, processing or does not meet the requirements, it will be return to customer and additional return cost will be deducted from account credit.

- Make sure to snug the packaging according to the product’s shape. Wrap the return product(s) with bubble wrap, then securely seal the box with tape. If using pouch packaging, ensure that you use the correct size of the padded pouch for the product.

- We will not be liable for any damage or loss caused to your return shipping due to improper packaging.

6. Return Address

ATTN : Return Department, Unit 17 / 22 Anzac Street, Greenacre NSW 2190

Please understand that provided Surgical fail or Mis-use return information will be included in TGA medical device annual report as well as adverse event report to comply with regulatory reporting requirements, Section 22. Post-market vigilance and monitoring requirements of the Australian Regulatory Guidance for Medical Devices (ARGMD). Return procedures and policies as stated are subject to change without prior notice.
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Types of Return* This field is required.
Surgical FailMisuse
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Customer Code* This field is required.PLEASE ENTER YOUR 6 or 7 DIGIT CUSTOMER CODE.
4
Clinic Name* This field is required.
5
Dentist Name* This field is required.
Dr.
Dr.
First Name
Last Name
6
Email* This field is required.
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code? or
Receiving the email may take a few minutes, thank you for your patience!
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Sales Representative Name* This field is required.
Insu Chung
Juno Jeong
Millicent Agius
Romein Jawansher
Scott Ryu
Suji Hong
Thong Truong
Victoria Angus
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Surgery Dates* This field is required.
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Return Product Information* This field is required.
10
Clinical Conditions Involved In The Event* This field is required.PLEASE SELECT ALL THAT CONDITIONS APPLY.
Pain
Numbness
Infection
Peri-implantitis
Significant bone loss
Necrosis around implant
Granulated tissue around implant
Sinus perforation
Nerve injury
Other
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Patient Information
PATIENT NAME
AGE
Please Select
Please Select
Male
Female
Non-Binary
SEX
MEDICAL HISTORY
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Customer SignatureI HEREBY CONFIRM THAT THE INFORMATION SUPPLIED HEREIN IS ACCURATE AND COMPLETE. THE PRODUCT BEING RETURNED HAS BEEN DECONTAMINATED AND CLEANED AND IS SAFE FOR HANDLING.
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