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Complaint Reporting

Facility, Issue, and Product Information

To report a KeriMedical complaint, CLICK HERE.

Please fill out the form below to file a report.

Quality Assurance Reporting

Quality Assurance Reporting

Initiated by*

Date Initiated*

Date of Incident*

Purchase Order

Contact Name*

Contact E-Mail*

Hospital/ASC*

Address*

City*

State*

Zip*

Contact Phone #*

Was a Patient Involved?*

Yes

No

Product Information:

Product Code*

Lot No.*

Set No.

Return Quantity*

Patient Information:

Age

Sex

Male

Female

Weight

Provide description of purported problem and events that occurred in the Operating Room. Describe any effects on the outcome of the surgery or on the patient.*

Is product being returned?*

Yes

No

Upload Photo

Do you need a shipping label provided for your return?*

Yes

No

Do you need a replacement?*

Yes

No

If a replacement is needed, please enter shipping information for the label below:

Recipient Name

Shipping Address

Ship to City

Ship to State

Ship to Zip

Recipient Phone

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Contact

Medartis Inc.

1195 Polk Drive
Warsaw, IN 46582

Information/Main: 574-376-2404
Corporate Fax : 574-966-1396
Order Hotline: 574-376-2399

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