Notification of Complaint
Date
*
-
Month
-
Day
Year
Date
Complaint Type
*
Please Select
Packaging
Product malfunction
Other
Item Number
*
Lot Number
Hospital Name
*
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
Please enter a valid phone number.
Please describe the problem below.
*
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Submit
FOR INTERNAL USE ONLY
Follow-Up
Date
-
Month
-
Day
Year
Person Handling:
Please Select
Donna Gurren
Tammy Gillespie
Kelly Partin
Staci Guberman
Jeff Vitullo
Notes:
Resolution
CAP Documents
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Results of investigation and corrective action(s) taken:
Replacements Sent?
Yes
No
Invoice Number for Replacements:
Credit Memo Number if credit issued:
Date Closed
-
Month
-
Day
Year
Should be Empty: