SkinPen (Crown Aesthetics Reportable incidents) SkinPen (Crown Aesthetics Reportable incidents) SECTION 1. CONTACT INFORMATION Name * Name First Name First Name Last Name Last Name Email * Customer number * Company/Clinic name * Country * SECTION 2. INCIDENT DETAILS Name of The Device/ Product * Approximate Date of Incident * Serial or Lot Number * Expiration Date (If Applicable) Details of The Incident * Upload Documentation * Upload file here Choose File Maximum file size: 516MB Check if section 3 is not applicable for you Not Applicable If complaint is not related to an Adverse Patient Event the following section will be marked "Not Applicable" and only section 1 and 3 require completion SECTION 3. ADVERSE EVENT TRIAGE QUESTIONS What Was The Date of The Procedure? What Area of The Body Was Treated? Was Medical Intervention Required? No Yes If Yes, Specify:If Yes, Specify: What Was The Purpose of The Treatment? Cosmetic Scar revision OtherOther Name of The Attending Physician/ Health Care Professional Is There Another Appointment With The Patient Scheduled? No Yes If Yes, what was the date of the next appointment: MM/DD/YYYYIf Yes, what was the date of the next appointment: MM/DD/YYYY Are There Pre and/ or Post Treatment Pictures Available No Yes Has There Been Any Resolution Since Incident/ Report? No Yes If yes, Specify:If yes, Specify: Did The Customer Request Additional Follow-up After Incident? No Yes If Yes, what was the date of the follow-up?If Yes, what was the date of the follow-up? SECTION 4. RESOLUTION Reporting Date * Reporter E-mail * Phone * Submit If you are human, leave this field blank.
