Delta Surgical QF-23 Complaint Form July 25

Customer Complaint Form

QF-23 Issue 2, July 25
Section 1, Customer Data

(Customer to Complete)
Date

DayMonthYear
Date
Name
Function/ Department
Company / Clinic
Address
Product Data (if applicable)
Product Code
Serial Number
Product Description
Complaint Details
Tick as appropriate:
Please Describe:
Was there a risk for a person/patient resulting by the use of the medical device?
If yes, please describe risk (maybe the injuries)
If yes, what was the date of the incident?
If yes, what was the name of the injured person?
If yes, did you inform a public authority
If yes, whom:
Before submitting this form please sign below
Once complete please select 'SUBMIT' to email a copy of the document to Delta Surgical

Product Data (if applicable)