Complaint
Complaint form

Customer Information

Date of event: *
Time of event: *
Hospital/Customer: *
Department: *
Contact person: *
Title:
Ort *
Address: *
Phone: *
E-mail: *

Product

Product code: *
LOT-/Serial number *

Add product

Description of event * :


Product type:

    Vascular accesses     NxStage/CARDIOsmart     Other dialysis products
Date of insertion: *
Blood loss (ml): *
Patientreaktion: *
Is the catheter present in patient: * Yes        No

What was used to clean the catheter/insertion site: *
Iodine
Chlorhexidine
Alcohol
Other     
Was acetone used: * Yes        No
Brand name of injection/needle-less cap used: *
Manufacturer of blood tubing set: *
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Kontrolltext :
Nordic Medcom AB, Box 491, 503 13 Borås       Tel: +46 (0)33 22 88 58       Fax: +46 (0)33 22 88 59