1 Step 1 Section 1: Your Information Hospital /Customer Name:your full name Complainantyour full name Mailing Address:your full name Departmentyour full name Dateof appointmentdate_range Cityyour full name Emaila valid emailemail Cell PhoneCell Phone Section 2: Information About The Product/Brand You Are Complaining Against Product NameProduct Name Manufacturer NameManufacturer Name Full Name of CompanyFull Name of Company Section 3: Complaint Information Product, ItemProduct, Item Date of PurchaseDate of Purchasedate_range Date of InstallationDate of Installationdate_range Local Supply (FOR) BusinessLocal Supply (FOR) Business Direct Import C&F Through L/CDirect Import C&F Through L/C Serial numberyour full name Manufacturer or BrandManufacturer or Brand ModelModel Under WarrantyYESNO Did You Sign a ContractYES NO Section 4: Details of Complaint(Please describe your complaint below, or attach a description of your complaint. Please type if possible) complaint is described in an attached documentIf your complaint will not fit in the box below, Commentsmore details0 / Submit Form keyboard_arrow_leftPrevious Nextkeyboard_arrow_right OUR SUCCESSFUL CLIENTS OUR PARTNERS
