Product Incident Report
Full Name:
Street Address:
City:
State/Province:
Postal Code:
Country:
Product Number:
Lot Number:
Qty:
Placement Date:
Incident Date:
Tooth #:
Patient Identifier:
Sex:
Age:
Medical Background:
Medical Background (Other):
Previous Implant Site:
Immediate Extraction:
Immediate Temporization:
Surgical Procedure:
Digital Guide:
Event Outcome:
Event Outcome (Other):
Site Grafted:
Antibiotics Given:
X-ray Taken:
Primary Failure Reason:
Primary Failure Reason (Other):
Primary Stability:
Immediate Load:
Fully Restored:
Bone Quality:
Secondary Failure Reason:
Secondary Failure Reason (Other):
Incident Detail:
Restorative Doctor:
Restorative Dr. Phone #:

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