Product Problems & Complaints
Product Complaints

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Product Problems / Complaints: A Secure Form

If you have experienced any problems with any Medcomp® product, please take a moment to complete the following complaint form. The information you provide will allow Medcomp® to fully evaluate the problem, and where appropriate, take measures to prevent a reoccurrence. Please provide as much detail regarding the incident as possible.

If you prefer you may print and fax this form to the attention of a Clinical Nurse Specialist at 215-256-0818.
Click here to print this page.

After receipt of this form a Medcomp® Clinical Nurse Specialist will contact you.

Contact Person: * indicates required field
Salutation: Dr. Mr. Mrs. Ms.
*First Name: M.I. (optional)
*Last Name:
*Title / Position:
*Phone:
Fax:
Email:
Company Clinic/Facility Other Organization
*Company Name:
*Street Address:
 
*City:
*State / Province:
*Zip / Postal Code:
*Country:
Incident: Same Location as Above
(click to copy fields)
*Hospital / Dialysis Unit:
*Street Address:
 
*City:
*State / Province:
*Zip / Postal Code:
*Country:
 
*Incident Date:
*Device Name:
Lot Number:
*Description of Incident (as detailed as possible):
Device Insertion Date:
Removal Date:
Patient Information (Required by FDA):
- ID# / Initials:
- Age:
- Sex:
- Weight:
- Diagnosis:
- Past Medical History:
- Catheter Site Care: Betadine Alcohol
Other:
- Disinfectant Trade Name:
 
*Product Available for Return for Evaluation? Yes No

If available please decontaminate and send to:
Medcomp®
ATTN: Clinical Nurse Specialist
1499 Delp Drive
Harleysville, PA 19438 USA
Additional Comments:
 
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PNW240 Rev. B 5/03