Ophthalmology Product Complaint Form

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):
Preferred follow-up contact:
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
Enter 0 if not applicable

Product Complaint Form

Step 3: Event Information
When was the defect identified?
Event date

MonthDayYear
Date
Specialty
Procedure type (if available)

Product Complaint Form

Step 5: Product Return Information
Can the defective product be returned?
Can the remaining product from the same box be returned? (if applicable)
Can Corza pick up the product at your location?
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?
If yes, should the response be sent to:
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: