Report a Product Complaint

Reporter Information (Please complete as many fileds as possible) :

First Name

Last Name

Gender

Male
Female

Age

Street Address :

City :

Province/Region/State :

Postal/Zip code :

Country

Phone Number :

Email Address :

Description of Complaint :

Patient ID Card Information (Please provide the Catalog & Serial/Lot Number) :

Catalog Number :

Serial Number :

Surgeon/Doctor Information :

Implant surgeon Name :

Implant Date :

Implant Institution Name :

Implant Institution Address :

City :

Province/Region/State :

Postal/Zip code:

Country :

Explant Surgeon Name :

Explant Date :

Implant Explain Name

Explant Institution Name :

Explant Institution Address :

City :

Province/Region/State :

Postal/Zip code :

Country :

Revision Surgeon Name :

Date :

Revision Institution Name :

Revision Institution Address :

City :

Province/Region/State :

Postal/Zip code :

Country :

After Procedure Information :

Have you kept the follow up visit schedule until the reported problem you shared?

Yes
No

If No, Please Explain :

Have you adhered to the dietary instructions you received from the implanting surgeon's team?

Yes
No

If No, Please Explain :

Do you give permission to request your medical records related to your LAP-BAND®?

Yes
No

If No, Please Explain :

Product complaint