IceCure Medical Ltd.
DSR3000000 rev.L
Confidential
User Manual
99
IceSense3™
14
CUSTOMER COMPLAINT FORM
Section 1: Customer complaint
(To be filled by customer / complaint recipient)
Complaint reported by: Phone FAX Email Letter
Sales representatives Website Other: __________________
Name: ________________
Title / Position: __________________
Address:
Phone: _____________________
Fax: ___________________
Product Name:
Batch No. :
Serial No. :
Description of complaint:
Initial consequences: Service
(No Harm)
Injury Death
If death or injury occurred, please describe below:
Complaint recorded by:
Name: _________________
Title / Position: _______________
On Date: _______________
Time: ________________
Signature: _________________
ATTENTION! IF DEATH OR INJURY OCCURRED NOTIFY IMMEDIATELY TO ALL
RELEVANT PERSONNEL ACCORDING TO PROCEDURES
