Product Feedback

Please provide the information requested below when submitting your product feedback. Areas indicated with an asterisk (*) are required data entry fields and must be completed to submit this Product Feedback Form.

Check this box if you work for Hologic.

Hologic awareness date

Submitter First Name

Submitter Last Name

Submitter Email Address

Submitter Phone Number

Submitter Country

Customer Contact Name

Same as above

Customer First Name

Customer Last Name

Customer Email Address

Customer Phone Number

Company Name

Company Address

Suite Number or Department Name

City/Town

State/Province

ZIP/Postal Code

Country

Hologic Account Number

Name of your Hologic Sales Representative

Date and Time of Event

Please provide a detailed description of the issue experienced

Select a product family

Date of implantation

Number of tags in surgical breast

ATEC Adapter Device part number (REF)

ATEC Biopsy Device part number (REF)

ATEC Biopsy Site Markers Device part number (REF)

ATEC Consoles Device part number (REF)

ATEC Introducer Localization (ILS) Device part number (REF)

ATEC Needle Guides Device part number (REF)

Ancillary Device part number (REF)

Brevera Biopsy Device Part Number (REF)

Celero Biopsy Device / Introducer Device part number (REF)

Celero Biopsy Site Markers Device part number (REF)

Contura Multi-Lumen Balloon Catheter part number (REF)

Duo System Localization Wire part number (REF)

Eviva Adapter Device part number (REF)

Eviva Biopsy Device part number (REF)

Eviva Biopsy Site Markers part number (REF)

Eviva Needle Guides part number(REF)

MammoPad part number (REF)

MammoSite Targeted Radiation Therapy part number (REF)

Sertera Biopsy Device/Introducer part number (REF)

Tuloc Localization Wire part details (REF)

Tumark Biopsy Site Markers part number (REF)

Tuflex part number (REF)

Lot/Serial Number

Lot/Serial Number of reported items

Quantity of defective product

Was there any harm to the patient or user?

Please provide a detailed description of the harm to the patient and/or user

Describe patient/user’s current status and whether medical intervention was required

Was the procedure completed successfully?

Yes, with the same device

Yes, with another device

No, procedure was aborted

Was there any additional medical or surgical intervention required?

Yes

Was this device used on a Hologic System?

Yes

Is the device in question available for investigation and analysis?

Yes

Asset Serial Number

Has the product been used on a patient or is it contaminated in any way? NOTE: Do not ship contaminated product back to Hologic prior to receiving a biohazard container

Yes

What address would you like the return kit shipped to? The return kit will include a biohazard container when contaminated products are being returned.

What address would you like the return kit shipped to? The return kit will include a biohazard container when contaminated products are being returned.

Same as above

Ship To First Name

Ship To Last Name

Ship To Address

Ship To Suite Number or Department Name

Ship To City

Ship To State

Ship To Zip Code

Ship To Country

Master template