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Hospital's name* Surg Departement*

Surgeon City*

Country* Dealer*

Reference* Description*

The performance of the medical device is fully satisfactory*YesNo

The medical device can be well decontaminated*YesNo

Incidents or other reportable events occured*YesNo

The medical device causes user interruption*YesNo

The medical device is misused or used for other purposes than those state on the label*YesNo

(new) Risks/hazards are associated with the medical device*YesNo

Are there other techniques replacing the product or other developments, e.g. in the area of workers safety or waste disposal?*YesNo

How satisfied are you with the product?*

First Name * Last Name *

Mail *

I have read the privacy policy and consent to the use of my personal data in accordance these provision.*

There for you with certainty

Gimmi^® GmbH
Carl-Zeiss-Strasse 6
78532 Tuttlingen
Germany

Phone +49 7461 965900
Fax +49 7461 9659033
Mail contact@gimmi.com