Registration form - Josef Ganter Feinmechanik GmbH

Josef Ganter Feinmechanik GmbH

Niedereschacher Straße 24
78083 Dauchingen

Telephone: +49 (0)7720 609950
Fax: +49 (0)7720 61264

E-mail: info@josefganter.de

Step

Administrative information

Reporting date *

Classification of the event *

Details of the reporting person

Name *

Contact *

Street / street number *

Post code / city *

Land *

Telephone *

Fax

E-mail *

Medical device details

Name of the product *

Model number *

Item number *

Serial number *

Batch no. *

Date of purchase *

Delivered by *

Date of delivery *

First use *

First sterilisation *

Event details

Date of the event *

Description of the event *

Where is the medical device at the moment? *

User of the medical device at the time of the event * *

Use of the medical device *

Patient details

Short-term and long-term consequences of the event *

Sex

Age of the patient at the time of the event

Weight (kg)

Details of the health facility

Name *

Contact *

Street / street number *

Post code / city *

Country *

Telephone *

Fax

E-mail *

I have taken notice of the privacy policy. *

Here you will find our data protection guidelines.
Note: All gender-specific forms used are to be viewed as gender-neutral. Here, all genders are spoken to equally.

* Mandatory information