Warranty Claim | Ideal Implant

This report is from*

Patient
Physician’s Office
Healthcare Facility

Specify Physician or Facility Name

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
Issue credit for replacement implant
Financial assistance - Will submit signed claim form and receipts.
Other

Other Requested Action

If you need help with this form or need to make changes after submission, please contact Ideal Implant Warranty Department at: 214-492-2500

Warranty Claim - Complaint Report

Patient Information

Implant Procedure

Implant Information

Requests

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