Product Complaint Form Contact InformationTitle(Required)TitleMr.Mrs.Ms.Dr.Full Name(Required)Email(Required) Phone(Required)Job Title/Position(Required)Job Title/PositionAdministratorMaterials ManagerMedical DoctorRegistered NurseSterile Processing TechnicianTechnicianOtherCompany Name (if applicable):Product InformationProduct Name:(Required)Part NumberLot/Batch Number(Required)Purchase Date(Required) MM slash DD slash YYYY Complaint Type(Required)(Select the type of Issue)Product DefectPerformance IssueSafety ConcernLabeling or Packaging IssueOther (Please specify)Detailed Description of the IssueWas Patient Involved ?(Required)Yes/NoYesNoIf Yes, Please Describe Any Patient Effects:(Required)OtherProduct Usage DetailsDate of Incident(Required) MM slash DD slash YYYY Usage Type(Required) First Use Repeated Use Additional InformationAction Taken by User (if any)(Required)Is Product Available for Return?(Required) Yes No Photo Upload (optional):(Required)Max. file size: 2 MB. Upload any relevant photos of the product or issue, if availableAcknowledgment By submitting this form, you confirm that the information provided is accurate and that you understand Makvin Surgical may contact you for additional information to support our investigation and quality improvement efforts.Consent(Required) By checking this box, you agree to our Terms and Conditions and Privacy Policy.(Required)
