NAME OF THE APPLICANT / CONTACT PERSON *
Reporting as * Healthcare institutionHealthcare WorkerCaregiverPatientInstallation/maintenance personOther
E-mail *
Telephone*
Product*chooseCRYO-S PAINLESSCRYO-S ELECTRIC IICRYO-S MINIProbes for CRYO-S devicesCRYO-T ELEPHANT GCRYO-T ELEPHANT MINI MCRYO-T ELEPHANT MINI GMCRYO-T ELEPHANT MINI GSCRYO-T COOLERSWING diode laserSWING diode laserTWIST diode laserBOA MAX 2 Massage DeviceBOA MINI+ Massage DeviceATO-3 Ozone Therapy DeviceArctica Classic Mini cryochamberArctica Classic Mini cryochamber without vestibuleother
SERIAL NUMBER/LOT* (if not known, enter "unknown")
PATIENT/USER INITIALS *
PATIENT/USER AGE * (at the time of the incident)
GENDER OF THE PATIENT / USER * womanmanother
DATE OF INCIDENT*
LOCATION OF THE INCIDENT*
INCIDENT DESCRIPTION*
PATIENT/USER EFFECTS *
CURRENT LOCATION OF THE PRODUCT* healthcare facilityat the patient/useron the way to the manufacturerthe product has been discarded / disposed ofunknown
PRODUCT USAGE* firstreuseproblem noticed before useafter service / complaintother
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