Originator (required)
Email (required)
Name of your organisation
Your Qualifications
Address (required)
Country
Telephone
Name of device (required)
Device Lot No.
Was the device intact and within its ‘Use By’ date when received? YesNo
Was the device used as intended and instructed in the IFU? YesNo
Customer feedback
If any, what were clinician’s notes/observation?
If any, what were patient’s comments/observation?
Date (required)
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