Ultherapy form Ultherapy form formular for at registrere Ultherapy events/issues Ultherapy Form - Appendix A-Field Experience Report Device in use Control Unit Handpiece Transducer * Description of Event/Issue Date event reported * Product issue * Product issue N/A (not applicable) Date of Event/Treatment * Patient-related issue * Patient related N/A (not applicable) Procedure being performed or Guideline used Patient Identifier Serious public health threat or death must be reported immediately. Has a serious public health threat or death occurred? * No Yes Event Description (sufficient incident description) * Actions Was a replacement or loaner provided? Replacement Loaner None Other Cellfina component Quantity PHYSICIAN/CLINIC/INSTITUTION Name of physician * Name of clinic * Address * Country * City, Zip/Postal Code * Telephone * Email adress * Fax Follow up report is requested Yes No FORM COMPLETED BY Has the event been reported to the local regulatory body? Case no. Has the event been reported to the local regulatory body? * Yes No N/A Attach support log file TO OBTAIN A SUPPORT LOG GUIDE - CLICK HERE Upload support log file and other relevant documents drop files here choose files Maximum upload size: 516MB reCAPTCHA If you are human, leave this field blank. Submit
