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:

ComplaintDefective ProductRequest of a GuaranteeReport of an Incident
Please Describe:
Was there a risk for a person/patient resulting by the use of the medical device?

YesNo
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

YesNo
If yes, whom:
Before submitting this form please sign below

Clear
Once complete please select 'SUBMIT' to email a copy of the document to Delta Surgical

Product Data (if applicable)