Product Incident Report - Non-Implant

To be able to complete the form, you must have your account number. This can be located xxx. If you do not have your account #, please reach out to Keystone or Paltop to obtain your Account #.

Customer Information

Full Name:*


Street Address:*
City:*
State/Province:*
Postal Code:*
Country:*
Product Number:*
Lot Number:*
Qty:*
Product Number 2:
Lot Number (Prod. #2):
Qty (Prod. #2):
Product Number 3:
Lot Number (Prod. #3):
Qty (Prod. #3):
Product Number 4:
Lot Number (Prod. #4):
Qty (Prod. #4):
Patient Identifier:*
Sex:*
Age:*
Medical Background:*
Medical Background (Other):
Previous Implant Site:*
Immediate Extraction:*
Immediate Temporization:*
Digital Guide:*
Placement Date:*
Removal Date:*
Event Outcome (Non-Implant):*
Event Outcome (Other):
Site Grafted:*
Antibiotics Given:*
X-ray Taken:*
Incident Detail:*

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