Contact Report Contact Report If you are human, leave this field blank. ABOUT YOU: Enter your name Enter your email address ABOUT THE EVENT: Date Company Agent Learned of Event Event Date Device User at Time of Event: Select one... Healthcare Professional Patient Lay Person Other ABOUT THE EVENT REPORTER TO B2B: Enter Name This is typically the patient, their caregiver, or a medical professional. Enter the Reporter Phone Number Enter the Reporter Email Address Source of Information Select one... Study Literature Consumer Healthcare Professional User Facility Company Representative Distributor Other ABOUT THE PATIENT: Patient Identifier Enter Patient Initials Patient Age Years and Months Patient Gender Select... Male Female Select Gender Patient Weight Lbs Patient Involvement Select one... Death Injury Needing Treatment Injury Without Treatment No Injury Description of Event or Problem Select one... Broken Detached Incompatible Other Description if Other Enter text description ABOUT THE DEVICE: Lot #s Enter text Devices Involved: 6.0 System Pedicle Screw 6.0 System Curved Rod 5.5 System pedicle screw- cannulated 5.5 System rod- curved 5.5 System connector- multi axial transverse 5.5 System connector- parallel System hook- open pedicular 5.5 System hook- thoracic offset PLIF TyPEEK cage Devices Involved 6.0 System Straight Rod 5.5 System pedicle screw- straight 5.5 System rod- straight 5.5 System connector- fixed transverse 5.5 System connector- end to end 5.5 System connector- open lateral 5.5 System hook- open laminar 5.5 System hook- lumbar offset Anterior Cervical Plate (ACP) UDI #s Enter text Are Devices being returned for investigation? Select one... Yes No Unknown reCAPTCHA SUBMIT CONTACT FORM