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Date of event:
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Name of the account issue occurred at:
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Address of the account issue occurred at:
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Name of person submitting issue:
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First
Last
Phone number of the person submitting issue:
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Email address of the person submitting issue:
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occurred applicable): number
Detailed Description of the issue:
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Device part number:
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Device serial number (if applicable):
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Device lot number:
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Quantity of devices affected:
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Approximate age of the affected device(s):
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Option to upload photo (if available): email to customerservice@turbettsurgical.com
Patient affected (yes/ no) if yes, provide details:
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Was a Medwatch Form 3500A or electronic equivalent filed in associated with this issue (yes/ no)? If yes, provide associated report number
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