COMPLAINTS QUESTIONNAIRE

COMPLAINTS QUESTIONNAIRE
1. Important Information
Please retain the physical product until the complaint has been fully resolved, as it may be required for further investigation.

A replacement will only be issued if a photo of the product is attached to the complaint form.

TRI® is only permitted to accept anonymized patient data.

Data containing identifiable patient details cannot be accepted.
2. Customer Details
Name of the clinic
Doctor / Technician Name
Customer Number
Country
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
E-Mail
example@example.com
Phone number

Country CodeOrtsvorwahlPhone Number
3. Type of Complaint
Select which kind of component you want to submit a complaint:
3.1. Implants
Implant Article Number
Implant Lot number
Patient ID
Tooth position
Implantation date

MonthDayYear
Date
Complication date

MonthDayYear
Date
Select Complication Occurred
Add Product Pictures (Mandatory for product replacement)

Cancelof
Add X-rays (anonymized)

Cancelof
Select Patient Symptoms
Have you identified one of these risk factors?
Why do you believe the complication occurred?
Could the patient be successfully retreated or do you have a plan for retreatment?
3.2 Abutments
Abutment Article Number
Abutment Lot number
Patient ID
Tooth position
Restoration date

MonthDayYear
Date
Complication date

MonthDayYear
Date
Select Complication Occurred
Add Product Pictures

Cancelof
Add X-rays (anonymized)

Cancelof
Have you identified one of these risk factors?
Why do you believe the complication occurred?
Could the patient be successfully retreated or do you have a plan for retreatment?
3.3 Instruments
Instrument Article Number
Instrument Lot Number
Patient ID
Complication date

MonthDayYear
Date
Select Complication Occurred
What was the insertion torque (Ncm):
Add Product Pictures

Cancelof
Have you identified one of these risk factors?
Why do you believe the complication occurred?
Could the patient be successfully retreated or do you have a plan for retreatment?
Declaration
4. Return Information
Important: Please only return products if specifically requested by TRI® Complaint Handling. If a return is required, ensure the product(s) are explanted, cleaned, and sterilized before shipping.

Please send the explanted, cleaned and sterilized product(s) to:

TRI®

z. H.: Complaint Handling

Merzhauserstraße 183

79100 Freiburg/Germany

For returns from the USA, please use the following adress:

TRI® Digital Hub

2850 Red Hill Ave, Suite 210

Santa Ana CA 92705

USA
Should be Empty:

COMPLAINTS QUESTIONNAIRE

1. Important Information

2. Customer Details

3. Type of Complaint

3.1. Implants

3.2 Abutments

3.3 Instruments

4. Return Information