Medical Device Product Complaint Form

Thank you for submitting your feedback on the Starviewer Medical Device Products.
Customer feedback and safety is very important to us.

Contact information
First name
Last name
E-mail address
Phone number
Preferred contact method Phone E-mail

Product information
Date of event / occurrence
Specific product
Product serial number (if applicable)

Problem description

Does the alleged complaint / order data provided involve any of the following:
Yes No Unknown
Was the patient or user affected?
Death of a person
Injury to a person
A malfunction which, if it happened again,
might cause or contribute to a death or injury?

Please describe: