Interacoustics Air Fx Mode D'emploi page 259

Opr. dato:
2008-10-03
Company:
Address:
Phone:
Fax or e-mail:
Contact person:
Following item is reported to be:
returned to INTERACOUSTICS for:
defective as described below with request of assistance
repaired locally as described below
showing general problems as described below
Item: Type:
Serial No.:
Included parts:
Description of problem or the repair performed locally:
Returned according to agreement with:
Date :
Please provide e-mail address or fax no. to whom Interacoustics may
confirm reception of the returned goods:
The above mentioned item is reported to be dangerous to patient or user
In order to ensure instant and effective treatment of returned goods, it is important that this form is filled in and
placed together with the item.
Please note that the goods must be carefully packed, preferably in original packing, in order to avoid damage
during transport (packing material may be ordered from Interacoustics).
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EC Medical Device Directive rules require immediate report to be sent, if the device by malfunction
deterioration of performance or characteristics and/or by inadequacy in labelling or instructions for use, has
caused or could have caused death or serious deterioration of health to patient or user.
Return Report
af: Rev. dato:
EC
Important! - Accessories used together with the item must be included if
returned (e.g. external power supply, headsets, transducers and couplers).
Interacoustics,
– Form 001
af:
HNI
Date:
repair, exchange,
Quantity:
Supplied by:
Other :
Person :
Rev. nr.:
4
Address
DGS Diagnostics Sp. Z o.o.
Ul. Wiosenna 5
72-006 Mierzyn, Szezecin
Polska
Phone
(+48) 91 441 7700
E-mail
info@interacoustics.com
other:
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