Kundenbeschwerde - KeriMedical

Recording Data

First Name*

Last Name*

E-mail Adress*

Phone number

Awareness date*

Country*

If your country is not listed, please specify it below.

Customer Data

Clinic/Hospital*

City, State

Surgeon Name*

First Name Last Name

Is a response requested by the surgeon?

Yes

Product Data

Product*

Product typeProduct Reference

Lot Number

Quantity

Bitte gib eine Zahl größer oder gleich 0 ein.

Equipment/Set Number

Complaint Information

When did the incident occur?

Pre-operative

Intra-operative

Post-operative

During Explantation

Date of Initial implantation

Description of symptoms

Date of onset of symptoms

Date of Revision/Failure Detection*

Description of defect/complaint*

How was the problem solved by the surgeon?

Upload photo (e.g. from reported issue)

Ziehe Dateien hier her oder

Akzeptierte Dateitypen: pdf, doc, docx, jpg, dcm, jfif, Max. Dateigröße: 5 MB, Max. Dateien: 50.

If you encounter any difficulties, please send the documents by email to complaints@kerimedical.com

Note: For data protection reasons, information such as X-ray images, operation reports and treatment reports must be sent by e-mail to complaints@kerimedical.com *X-ray recommendations in case of a Touch revision surgery: Preoperative, initial postoperative, and before- and after-revision surgeries (dated and anonymized), showing the metacarpal in anteroposterior and lateral views, as well as the trapezium with all joint spaces visible. By submitting this form, you declare that all the information is true and correct to the best of your ability.

Will the Product be returned?

Yes

Note: Product can only be returned in a cleaned condition + proof of cleaning.  Download device return form

Patient Impact and Data

Patient age

Patient gender

Patient profile (activitiy level, hobbies, comorbidities)

Did the incident result in, or could it have resulted in a risk to patient safety?

Yes

Did the incident cause any surgical delay?

Yes (< 30 minutes)

Yes (> 30 minutes)

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