Complaint Report - Ideal Implant

This report is from*

Patient
Physician's Office
Healthcare Facility
Other

Specify Physician or Facility Name

Specify Other Reporter

Name of Person Completing this Report*

First Last

Date*

Email*

Phone*

Street Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Reporter also sent report to regulatory authority?*

No
Yes

Specify Regulatory Authority

Date of Complaint Onset*

Complaint Involves*

Complaint Summary*

Patient Information

Name*

First Last

Date of Birth*

Implant Procedure

Date of Procedure Known?*

Date Unknown
Date Known

Date

For:*

Implanting Surgeon*

Not Known
Known - Reporting Physician
Known - Other Physician

Name of Other Physician

Implant Information

Implant Complaint*

Implant Size*

Is Serial Number Known?*

No
Yes

Serial Number

7 Digits

Is Reoperation Planned?*

No
Yes, reoperation is scheduled
Reoperation has been done

Approximate Date:

Select Scheduled Procedure:

Completed Reoperation Date:

Select Completed Procedure:

Specify Other Reoperation Procedure

Explant Information

No replacement
Replacement with IDEAL IMPLANT
Replacement with other manufacturer's implant

Explanting Surgeon

Not Known
Known - Reporting Physician
Known - Other Physician (specify)

Reoperating Surgeon

Not Known
Known - Reporting Physician
Known - Other Physician (specify)

Other Physician Name

Requests

Requested Action(s)

Send explant kit

Other Requested Action