Medical Device Injury Case Evaluation
Please provide detailed information about the medical device injury incident to help us assess your case.
Full Name of the Person Reporting or Affected
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Incident
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Incident
*
Medical Device Name and Model
*
Describe the Incident and How the Injury Occurred
*
Type of Injury Sustained
*
Burn
Cut/Laceration
Infection
Allergic Reaction
Bruising
Other
Severity of Injury
*
Mild
Moderate
Severe
Was Medical Treatment Required?
*
Yes
No
Please Describe the Treatment Received (if any)
Was the Medical Device Removed or Replaced?
*
Removed
Replaced
No Change
Were Medical Professionals Involved?
*
Yes
No
Please Upload Any Relevant Documents or Photos
Upload a File
Drag and drop files here
Choose a file
Cancel
of
Submit Case
Should be Empty: