Online Complaint Form

Thank you for accessing Aesculap's On-line Complaint Form. Please complete the fields to the best of your knowledge with facts only. The Aesculap Quality Department will contact you within 48 hours with a complaint number and product return instructions.

Account Information

Note: Contact Person Required for Replacement

Customer Facility:

Account Number:

Contact Person:

Title:

Address:

Address 2:

City:

State:

Zip:

Phone # (required for credit):

Submitter Email (required for credit):

Contact Email:

Type of Inventory:

Regular Sales

Consigned

Sample/Product Information

Note: Set number, where applicable, is REQUIRED to remove the item from the account.

Purchase Order:

Date of Purchase
2-digit month, 2-digit day, 4-digit year: XX/XX/XXXX:

Catalog Number:

Lot Number:

Complete Set Number (where applicable, is REQUIRED to remove from the account):

Quantity Affected:

Is this device available for evaluation?

Yes

Quantity to be Returned:

Shipping label to Rep or Contact?:

Complaint Information

Note: CONTACT THE QUALITY GROUP BY PHONE IF ANY PATIENT INJURY IS REPORTED.

Did the incident occur in surgery?

Yes

If not, where? (i.e. central sterile):

Did this incident cause or contribute to serious injury or death?

Yes

If yes, who was impacted (i.e. staff, patient)?:

Did this incident cause or contribute to a delay in surgery?

Yes

If so, how long? (if the exact time is unknown, please estimate, i.e. less than 5 minutes, 5-10 minutes, etc):

Detailed Description of Incident

Note: Report facts only

Please provide a brief description of what was happening during the incident. (Required to submit complaint)

Date incident occurred (required field)
2-digit month, 2-digit day, 4-digit year: XX/XX/XXXX:

Date of surgery
2-digit month, 2-digit day, 4-digit year: XX/XX/XXXX:

Type of procedure:

Was additional intervention needed? (i.e. X-ray, piece retrieval or additional medicine):

Field Information

Date of Aesculap Employee becoming aware of complaint: XX/XX/XXXX (Required to submit complaint):

Representative

Aesculap Sales Rep

Aesculap Implant Sales Rep

Distributor Rep

Unknown

Sales Representative:

Regional Manager:

NOTE: IF SUBMITTING MORE THAN ONE DEVICE, PLEASE SELECT 'SUBMIT ANOTHER DEVICE'. COMPLETE NEW FORM FOR SEPARATE FACILITY.

IMPORTANT INFORMATION: DEVICES THAT HAVE BEEN USED MUST BE DECONTAMINATED BEFORE RETURNING TO AESCULAP WITH ACCOMPANYING DECONTAMINATION FORM. THE QUALITY DEPARTMENT WILL PROVIDE A DECONTAMINATION FORM ALONG WITH RETURN INSTRUCTIONS UPON REVIEW OF THE SUBMISSION.