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Recording Data
First Name
*
Last Name
*
E-mail Adress
*
Phone number
Awareness date
*
MM slash DD slash YYYY
Customer Data
Clinic/Hospital
*
City, State
*
Surgeon First Name
Surgeon Last Name
*
Is a response requested by the surgeon?
Yes
No
Product Data
Product
*
Product type
TOUCH® CMC 1
Instrument TOUCH®
KeriFlex®
Instrument KeriFlex®
Product type
Product Reference
Product Reference
Lot Number
Quantity
Please enter a number greater than or equal to
0
.
Equipment/Set Number
Complaint Information
When did the incident occur?
*
Pre-operative
Intra-operative
Post-operative
During Explantation
Date of Initial implantation
MM slash DD slash YYYY
Description of symptoms
Date of Onset of symptoms
MM slash DD slash YYYY
Date of Revision/Failure Detection
*
MM slash DD slash YYYY
Description of defect/complaint
*
How was the problem solved by the surgeon?
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Note: For data protection reasons, information such as X-ray images, operation reports and treatment reports must be sent by e-mail to
UScomplaints@kerimedical.com
*X-ray recommendations in case of a Touch revision surgery: Preoperative, initial postoperative, and before- and after-revision surgeries (dated and anonymized), showing the metacarpal in anteroposterior and lateral views, as well as the trapezium with all joint spaces visible. By submitting this form, you declare that all the information is true and correct to the best of your ability.
Will the Product be returned?
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Do you need a replacement ?
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Patient Impact and Data
Patient age
Patient gender
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Patient profile (activitiy level, hobbies, comorbidities)
Did the incident result in, or could it have resulted in a risk to patient safety?
*
Yes
No
Did the incident cause any surgical delay?
Yes (< 30 minutes)
Yes (> 30 minutes)
No
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