Report an incident - Metrum Cryoflex

APPLICANT'S NAME / CONTACT PERSON *

I REPORT AS *Healthcare institutionHealthcare professionalKeeperPatientInstaller / maintenance personOther

E-MAIL ADRESS *

PHONE NUMBER *

DEVICE *

SERIAL NUMBER/LOT * (if not known, enter "unknown")

PATIENT/USER INITIALS *

PATIENT/USER AGE * (at the time of the incident)

PATIENT/USER GENDER *femalemaleother

DATE OF THE INCIDENT *

LOCATION OF THE INCIDENT *

DESCRIPTION OF THE INCIDENT *

PATIENT/USER IMPACT *

CURRENT LOCATION OF THE DEVICE *a healthcare facilityon the patient / useron the way to the producerthe product has been discarded / disposed ofunknown

PRODUCT USE *firstreuseproblem noticed before useafter service / complaintother

Note: All information regarding your notification can be obtained at: pms@metrum.com.pl

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