Neoss Customer Complaint Form

Fields marked with * are mandatory, complete other fields as appropriate. Send one form per patient.

Account number

Postal/Zip code

Clinic name

Email contact

Street

Contact name

City

Phone

Country

Article number	Article name	Batch/Lot number	Initial use date (MM/DD/YYYY)	Date of problem (MM/DD/YYYY)	Implant position

Event type

Event description

Did the event lead to any of the following: Patient death, life-threatening illness, or permanent impairment of a body function?

Did the device cause or contribute to the event?

Was implant restored with Neoss original prosthesis?

Prosthesis type

Temporary or permanent prosthesis

Oral hygiene

Medical History