Wound Closure Product Complaint Form 2025

Product Complaint Form

Step 1: Reporter information
Reporter name*

First NameLast Name
Title/role*
Company or facility name*
Email address*
example@example.com
Phone number*

Country CodeArea CodePhone Number
Location address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Reporter type (select one):*

Distributor partnerHealthcare back office or healthcare provider non-userHealthcare provider and end userCorza employee
Preferred follow-up contact:*

Reporter onlyInclude healthcare provider/user (if different from reporter)
Provide healthcare provider/user contact information: *

Product Complaint Form

Step 2: Product & Lot Information
Product name/description
Catalog number (if available)
Order number*
If not available, please provide any order number, invoice number, or shipment date.
Lot number(s) (as printed on the box) *
If not available, please provide any order number, invoice number, or shipment date.
Quantity defective (# of pieces)
Enter 0 if not applicable
Quantity defective (# of boxes)
Enter 0 if not applicable

Product Complaint Form

Step 3: Event Information
When was the defect identified?

During inspection (before use)Preoperative (product prepared but not yet used)Intraoperative (during procedure)Postoperative (after procedure)
Event date*

MonthDayYear
Date
Specialty
Procedure type (if available)
What type of tissue/organ was involved in the procedure?

Product Complaint Form

Step 5: Product Return Information
Can the defective product be returned?

YesNo
Can the remaining product from the same box be returned?

YesNo
Can Corza pick up the product at your location?

YesNo, I would prefer to ship the remaining product to Corza
Please provide any pickup or shipping instructions. If location is different from what was entered previously, please provide updated information here.

Product Complaint Form

Step 7: Response Letter Request
Would you like to receive a formal response letter from Corza?

YesNo
If yes, should the response be sent to:

ReporterHealthcare provider/end userBoth
Provide any additional contact information (name, email, address) for delivery of response letter if in addition to what was previously included in this form.
Should be Empty: