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Clinical Professional / Authorised Dealer:_________________________________________________
Address:________________________________City:______________________________________
State:_______Post Code#:_____________tel:__________________fax:_______________________
Base:_____________________________________ Serial #:________________________________
Versa system:__________________________________ Serial #:____________________________
Order Details: Invoice #_______________________________Date: _________________________
Shipping Doc. #:__________________________________ Date: ____________________________
Date of incident: __________________________________________________ ____ __________ _ __
Description of incident: ______________________________________________________________
__________________________________________________________________________________
Causes (accidental, collision, not correct operation, structural failure, etc.)______________________
_________________________________________________________________________________
Component: ______________________________________________________________________
Related to the following part : ______________________________________ Quantity:___________
Severe injuries: ____________________________________________________________________
Rapair in safety conditions:
Component to be replaced:___________________________________________________________
Related to the following part: ____________________________________Quantity:______________
Note:____________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
To be sent immediately to the producer at the following fax: +39 - 0831. 730739
Annex 2 - Monitor of any after-sale incidents
O No
O Yes (continue to fill in the form)
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