Customer Feedback Form

Feedback – Completed by the individual receiving the information

  • Received By
  • Date Received
  • Customer Contact Name
  • Customer Phone number
  • Customer Email
  • Customer Facility name
  • Customer Address

USA Device(s) Affected

(Hold Control to select multiple devices)
-----Skylife Products-----

  • Skylife System Hospital (SKY-HOS)

  • Skylife System Home (SKY-HOM)

  • Cloud Cover (CC)

  • CloudCover Plus (CCP)

  • GelMat (SKY-GEL)

  • Control Unit & Power Supply (SKY-CON)

  • Light Module (SKY-LIM)

  • Eye Protection (EP1X)
    -----International Skylife Products-----

  • Skylife System with Travel Case (SKY-HOCA)

  • Skylife System Hospital (SKY-HOSI)

  • Skylife System Home (SKY-HOMI)
    -----ICON Products-----

  • Phoenix ICON™ Cart (PCI 40-1001)

  • Phoenix ICON™ GO System (PCI 40-2001)

  • Camera Hand Piece (PCI 40-1002)

  • Phoenix CONNECT (PCI 40-3000)

  • Fluorescein Module (PCI 40-1004)
    -----ICON Products-----

  • PAL (PAL-HOS)

  • PAL Disposable Sensor (PDS-10)

  • Description of Feedback

  • Patient Involved?
    Select one...
    Yes
    No

  • Injury or Death?
    Select one...
    None
    Injury
    Death

  • Device to be Returned?
    Select one...
    Yes
    No

Thank you! Your submission has been received!

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Form QA-711.1FM Rev D

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