Claims / Material vigilance

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General information
Date			Your reference
Name *			First name*
Title			Phone *
Email *			Fax
Company			User Distributor
Address *
Information about the device
Réf.			Name
Batch n°			Description
Claim description
Date of incident			Did the incident cause :
			Injuries	yes   no
			Death	yes    no
Sample
Have you kept one or more samples?			yes   no
If so, how many ?
Have you sent back the samples?			yes    no
Do you need help to send them back ?			yes    no
Comments
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ENTRAL by Maxter Catheters - Rue Anne Gacon - 13016 MARSEILLE - France - Tel : (33) (0)4.91.46.73.05 - Fax : (33) (0)4.91.46.73.48