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Medical Facility where the Feedback Originated

Customer contact name

Job title or Occupation

If this is related to a safety issue (possible injury, injury, or death) select yes, otherwise select no.

Please enter the model or part number.

Please enter the product serial/ lot number / software revision if available.

Description of the issue you are reporting. PLEASE DO NOT INCLUDE PHI.

Is your request low, normal, high, or urgent priority?

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