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Claims / Material vigilance

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General information

Date   Your reference
Name * First name*
Title  Phone *
Email * Fax 
Company User Distributor
Address *

Information about the device

Réf.    Name 
Batch n°  

Description


Claim description

Date of incident   Did the incident cause :
     

Injuries

yes   no  
      Death yes    no  

Sample

Have you kept one or more samples?   yes   no  
If so, how many ?       
Have you sent back the samples?   yes    no  
Do you need help to send them back ?   yes    no  

Comments

     

 

 

ENTRAL by Maxter Catheters - Rue Anne Gacon - 13016 MARSEILLE - France - Tel : (33) (0)4.91.46.73.05 - Fax : (33) (0)4.91.46.73.48