Customer Complaint Notification 1. Customer / Operator / Submitters *required Organisation Name* Contact Name* Contact EMail* Adress* Country* Phone* 2. Device Identifiation Model Description* Model No.* Lot / SN* Manufacturing date n.a. Expiry date n.a. 3. Application Date when device has been implanted Date when device was explanted Date when the complaint was identified 4. Complaint Provide a comprehensive description of the complaint, including (1) what went wrong with the device (if applicable) and (2) a description of the health effects (if applicable), i.e. clinical signs, symptoms, conditions as well as the overall health impact:* Number of Patients involved* -please choose an option-12345678910>10 Has the incident already been reported?* -please choose an option-NoYes - please explain to which authority If Yes, Name of Authority 5. General Comments I hereby accept to submit my data to General Implants GmbH Deutschland for processing the Customer Complaint Notification Submit