Medical Supplies & Services

Medical Device Complaint Form

Customer name *:

Institution:

City:

Phone No*

Device*

Model*

Serial-No*

Date Occurrence of Failure*

Date Complaint registered:

Customer expects Response within?

When did the Failureoccur*

Failure Description*

Replacement initiated:

Yes NO already done

Customer expects Response within?

Who provided the service

Please explain the problem

Health Condition of Patient ,User when Incident occurred:

Health Condition of Patient/User after Medical Intervention:

Health Condition of Patient/User today

Further Patient Information

Customer Information *: