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If you have experienced any problems or complaints with any Surgimedik product, please take a moment to complete the following complaint form. The information you provide will allow Surgimedik to fully evaluate the problem & take measures to prevent a reoccurrence. Please provide as much detail regarding the incident as possible.
Initiated by
Name *
Address *
City *
Country *
Zip
Contact No. *
Email *
Lot No.
Nature of
Complaint
Date Of Occurrence

Type of Procedure
Technique

Approach
No. of reuses

Method of Sterilization

Was Patient Involved Yes No

Quantity Involved
If Yes, ( Required by FDA)
Patient Name
Age of Patient

Sex

Weight
Diagnosis
Past Medical History
(* Feilds are mandatory)  
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SURGIMEDIK Healthcare India Pvt. Ltd.
SURGIMEDIK House, 53-CD, Kandivali Industrial Estate, Charkop, Kandivali (W), Mumbai 400 067.
Tel: 91-22-28609401, Fax: 91-22-28609404
E-mail: info@surgimedik.com .

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