Product Incident Report - Implant

Customer Information

Full Name:*


Street Address:*
City:*
State/Province:*
Postal Code:*
Country:*

Product Information

Product Number:*
Lot Number:* (If not known, please enter "Unknown")
Qty:*
Placement Date:*
Incident Date:*
Tooth #:*

Patient and Procedure Information

Patient Identifier:*(Please provide the patient's initials or identifier you use for the patient in your system)
Sex:*
Age:*
Medical Background:* (Please select all that applies. If "Other", please enter details in the box below)
Medical Background (Other):


Procedure Details

Previous Implant Site:
Immediate Extraction:
Immediate Temporization:
Surgical Procedure:*
Digital Guide:

Event Outcome

Outcome:* (Please select all that applies. If "Other", please enter details in the box below)
Event Outcome (Other):


Additional Details

Site Grafted:*
Antibiotics Given:*
X-ray Taken:*

Incident Information

Primary Failure Reason:* (Please select one. If "Other", please enter details in the box below)
Primary Failure Reason (Other):


Primary Stability:
Immediate Load:
Fully Restored:
Bone Quality:
Secondary Failure Reason:* (Please select one. If none, please select "None")
Secondary Failure Reason (Other):


Incident Detail: (Please provide a brief description of the incident)


Restorative Doctor:
Restorative Dr. Phone #:

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