VTI Online CIR
Vertebral Technologies Customer Input Report
* Required
Contact Name
*
Person completing this form
Contact Information
*
phone or e-mail for follow-up
User Name
*
Person using the device (Enter N/A if not applicable)
User Address (i.e. hospital)
*
(At least City and State, enter N/A if not applicable)
Date of Occurrence
*
format mm/dd/yy
Describe Customer Input
*
Include as much detail as possible to adequately describe input
Product Description
(if applicable)
Part Number
*
Enter REF # on device (Enter N/A if not device related)
Lot Number
*
Enter lot number of device (Enter N/A if not device related)