Customer Feedback Form/ Incident Report
Date of complaint
Name of Surgeon
Name of Facility
Was the product being used in surgery at the time of the incident ?
Was the procedure delayed ?
If Yes, how long was the procedure delayed?
Less than 30 Minutes
30 Minutes to 1 Hour
More than 1 Hour
Did the incident involve injury to the patient ?
If "yes" please describe the injury here
Were there any other devices being used with our device ?
If "yes" please list the devices here
Will the device be returned to GENICON ?
Is a Vigilance/MDR report required?
Please describe the incident in as much detail as possible
File or Picture Upload
Click to edit
Should be Empty: