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Opr. dato:
2014-03-07
Company:
Address:
Phone:
e-mail:
Contact person:
Following item is reported to be:
returned to INTERACOUSTICS for:
defective as described below with request of assistance
repaired locally as described below
showing general problems as described below
Item:
Type:
Serial No.:
Included parts:
Description of problem or the performed local repair:
Returned according to agreement with:
Date :
Please provide e-mail address to whom Interacoustics may confirm
reception of the returned goods:
The above mentioned item is reported to be dangerous to patient or user
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)
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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
Return Report
af:
Rev. dato: 30.01.2023
EC
Important! - Accessories used together with the item must be included if
returned (e.g. external power supply, headsets, transducers and couplers).
Interacoustics,
.
– Form 001
af:
MHNG
Date:
repair,
exchange,
Quantity:
Supplied by:
Other :
Person :
Rev. nr.:
5
Address
DGS Diagnostics Sp. z o.o.
Rosówek 43
72-001 Kołbaskowo
Poland
Mail:
rma-diagnostics@dgs-diagnostics.com
other:
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