Return Report – Form 001
Opr. dato: af:
2014-03-07 EC
Rev. dato: 2015-04-15 af:
MSt
Company:
Address:
Phone:
Fax
or
e-mail:
Address
DGS Diagnostics Sp. z o.o.
ul. Sloneczny Sad 4d
72-002 Doluje
Polska
Contact
person:
Date:
Following item is reported to be:
returned
to
INTERACOUSTICS
for:
repair,
exchange,
other:
defective as described below with request of assistance
repaired locally as described below
showing general problems as described below
Item: Type: Quantity:
Serial No.: Supplied by:
Included parts:
Important! - Accessories used together with the item must be included if
returned (e.g. external power supply, headsets, transducers and couplers).
Description of problem or the performed local repair:
Returned according to agreement with:
Interacoustics, Other :
Date : Person :
Please provide e-mail address or fax No. to whom Interacoustics may
confirm reception of the returned goods:
The above mentioned item is reported to be dangerous to patient or user
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In order to ensure instant and effective treatment of returned goods, it is important that this form is filled in
and placed together with the item.
Please note that the goods must be carefully packed, preferably in original packing, in order to avoid damage
during transport. (Packing material may be ordered from Interacoustics)
1
EC Medical Device Directive rules require immediate report to be sent, if the device by malfunction
deterioration of performance or characteristics and/or by inadequacy in labelling or instructions for use, has
caused or could have caused death or serious deterioration of health to patient or user.Page 1 of
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