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Complaint Form for one product A. Customer Information

B. Product information

Account Nr.:

Instruments

Doctor's Name:

Implant Prosthetics

Address:

Part Number.: Lot Nr.:

Surgical Doctor: Item returned:

Yes

No

Stamp: returned quantity

For Instruments fill only C out C. Complaint Reason Specification Product problem

Yes

No

Wrong delivery

Yes

No

For Implants and Prothetics fill D - F out D. General Patient information Gender:

E. Chronological order of events Male

Female

Placement Date:

Name of the Patient: Date of 2nd Stage: Age at time of placement:

Years Date of Event:

Bone Type: Tooth-Nr.:

Removal Date: Medical History:

F. Description of Event

Trouble:

Yes

No

Pain:

Yes

No

No primary stability:

Yes

No

Infection:

Yes

No

Not osseointegratet:

Yes

No

Swelling:

Yes

No

Failure of product:

Yes

No

Dehiscence:

Yes

No

Bone loss:

Yes

No

Inflammation:

Yes

No

Smoker:

Yes

No

Bruxism:

Yes

No

Yes

No

Others:

Other: Health befor operation: Other products were used in connection with the queried product:

Oral hygiene: Diabetes: Other disease:

*Extract of some double indicators from the packet supplement

Was the implant replaced?

Yes

No

When Yes: within 4 months?

Yes

No

Check list of documents to be enclosed: Photos Radiographs OP/supply report Please send us the full form by fax to our fax no.: +41 44 5678101

G. Signature of the Implantolog/ Date:

ID Complaint Form (EU-EN)  

ID Complaint Form (EU-EN)

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