Customer complaint

Practice/dental care provider/lab information

Customer number

Name*

Street address*

Zip code*

City*

Country*

Contacts*

Telephone number*

E-Mail*

Product (implant, component, instrument, etc.)

System*

Zeramex XT Zeramex P6 Zeramex T-Lock Zeramex P Zeramex T

Zeramex

Item name*

Item number*

Batch number*

By-product, if any

Date of incident*

Type of incident

Type*

Description*

Position*

Complete / send

Product enclosed

Other annexes

Product will be sent subsequently because

Product will not be sent because

Requested replacement

Upload files / photos (max. 5)

Date*

Das Produkt wurde gemäss der Gebrauchsanweisung (IFU) benutzt. Ich habe die Zeramex® Garantiebedingungen gelesen und akzeptiert. Ich habe die beanstandeten Produkte sterilisiert (Reinigung ist nicht nötig) und den Schutzbeutel als STERIL markiert. Ich habe diesem Formular das/die beanstandete/n Produkt/e und Röntgenbilder beigelegt. I hereby confirm that all of the information I have provided is correct. I acknowledge that customer complaints can only be processed once the product which is the subject of the complaint has been received.

I have read the Privacy Policy and accept it.

Information

Practice/dental care provider/lab information

Product (implant, component, instrument, etc.)

Type of incident

Patient information

Complete / send