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. Submitter First Name Submitter Last Name Submitter Email Address Submitter Phone Number Submitter Country - Select -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta and MelillaChadChileChinaChristmas IslandClipperton IslandCocos [Keeling] IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau SAR ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar [Burma]NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaSão Tomé and PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Customer Contact Name Same as above Customer First Name Customer Last Name Customer Email Address Customer Phone Number Company Name Company Address Company Address Suite Number of Department Name City/Town Zip/Postal Code Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta and MelillaChadChileChinaChristmas IslandClipperton IslandCocos [Keeling] IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau SAR ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar [Burma]NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaSão Tomé and PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Company Internal Reference Number Name of your Hologic Sales Representative Name of your Hologic Clinical Education Specialist Date and Time of Event Date Time Please provide a detailed description of the issue experienced Select a product family - Select -ATEC AdapterATEC Biopsy DeviceATEC Biopsy Site MarkersATEC ConsolesATEC Introducer Localization Sets (ILS)ATEC Needle GuidesAbrivo Biopsy Device/IntroducerAncillary ProductsBrevera Biopsy needle DeviceBrevera AdapterBrevera ConsoleBrevera DriverBrevera spare Tissue filterCelero Biopsy Device/IntroducerCelero Biopsy Site MarkersContura Multi-Lumen Balloon CatheterEviva AdapterEviva Biopsy DeviceEviva Biopsy Site MarkersEviva Needle GuidesMammoPadMammoSite Targeted Radiation TherapySertera Biopsy Device/IntroducerTumark Biopsy Site Markers ATEC Adapter Device part number (REF) - None -ATEC STX-1ATEC STX-2ATEC STX-2FATEC STX-FischerOther ATEC Biopsy Device part number (REF) - None -ATEC 0909-12ATEC 0909-20ATEC 0912-12ATEC 0912-20ATEC 0914-12MRATEC 0914-20ATEC 0914-20MRATEC 1209-20ATEC 1212-20 ATEC Biopsy Site Markers Device part number (REF) - None -SMark-ATEC-13-09SMark-ATEC-13-12SMark-ATEC-2S-13-09SMark-ATEC-2S-13-12SMark-ATEC-2S-36-09SMark-ATEC-2S-36-12SMark-ATEC-36-09SMark-ATEC-36-12SMark-A1309-ss1SMark-A1309-ss2SMark-A1312-ss1SMark-A1312-ss2SMark-A3609-ss1SMark-A3609-ss2SMark-A3609-ss3SMark-M-ss1SMark-M-ss2SMark-M-ss3TriMark TD 13-09TriMark TD 13-12TriMark TD 13-MRTriMark TD 36-09TriMark TD 36-12TriMark TD-2S-13-09TriMark TD-2S-13-12TriMark TD-2S-13-MRTriMark TD-2S-36-09TriMark TD-2S-36-12 ATEC Consoles Device part number (REF) - None -ATEC EmeraldATEC Emerald25ATEC PearlATEC Pearl25ATEC SapphireATEC Sapphire25C115 ATEC Introducer Localization (ILS) Device part number (REF) - None -ILS 0914-12ILS 0914-12OBILS 0914-20ILS 0914-20OB ATEC Needle Guides Device part number (REF) - None -ATEC NG09ATEC NG09A1ATEC NG09A2ATEC NG09FATEC NG12ATEC NG12FOther Abrivo Biopsy Device / Introducer Device part number (REF) - None -Abrivo1410AbrivoIntro1410 Ancillary Device part number (REF) - None -AI090920AI091220AI120920AI121220ATEC CanisterATEC NG09ATEC NG09-A1ATEC NG09-A2ATEC NG09FATEC NG12ATEC NG12FATEC RTFAATEC TF-1AbrivoIntro1410Celero Intro-12ILS 0914-12ILS 0914-20MME-00344 Fischer Draping KitMME-00345 Breast Biopsy TrayMME-00346 Stage Draping KitMME-00347 MultiCare Draping KitMME-01782 Breast Biopsy Kit (without lidocaine)SR 6146-02SR 6408-02SR 6408-03SR 6423-01Other Celero Biopsy Device / Introducer Device part number (REF) - None -Celero Intro-12Celero 12 Celero Biopsy Site Markers Device part number (REF) - None -CeleroMarkCeleroMark-2SSMark CeleroSMark Celero-2SSMark-U-ss1SMark-U-ss2SMark-U-ss3Other Contura Multi-Lumen Balloon Catheter part number (REF) - None -B01245B01256B01345B01356B03245B11245B11256B13245B13256B90003B90004B90009B90012WINDSTONE Eviva Adapter Device part number (REF) - None -EVIVA_ADAPTER / SV10039-01EVIVA_ADAPTER_GE / FAB-06337EVIVA_ADAPTER_MTEST / SV10171-01EVIVA_BUSHING_GEEVIVA_CALIBRATE_13CM / SV10167-02EVIVA_NG_HOLDER / SV10125-01EVIVA_STYLET_BRACKET / SV10114-01 Eviva Biopsy Device part number (REF) - None -EVIVA_0910-12 EVIVA_0910-12TEVIVA_0910-20EVIVA_0913-12EVIVA_0913-12TEVIVA_0913-20EVIVA_1210-20EVIVA_1213-20 Eviva Biopsy Site Markers part number (REF) - None -SMark-E10-ss1SMark-E10-ss2SMark-E10-ss3SMark-E13-ss1SMark-E13-ss2SMark-E13-ss3SMark-Eviva-10SMark-Eviva-13SMark-Eviva-2S-10SMark-Eviva-2S-13TriMark-Eviva-10TriMark-Eviva-13TriMark-Eviva-2S-10 Eviva Needle Guides part number(REF) - None -EVIVA_NG09LEVIVA_NG09REVIVA_NG12LEVIVA_NG12ROther MammoPad part number (REF) - None -MP101MP201MP301 MammoSite Targeted Radiation Therapy part number (REF) - None -819001819002819003926000919004919007-01ML2345MLMW08WINDSTONE Sertera Biopsy Device/Introducer part number (REF) - None -Sertera-12Sertera-14Sertera Intro-12Sertera Intro-14 Tumark Biopsy Site Markers part number (REF) - None -Tumark Vision 10 cmTumark Vision 12 cmTumark Professional Q 10 cmTumark Professional Q 12 cmTumark Professional X 10 cmTumark Professional X 12 cmTumark Flex for ATEC 9 GTumark Flex for ATEC 12 G Lot Number and/or Serial Number (LOT and/or SN) - Select -Provide NumberUnknown Provide Number Quantity of product possibly defective Was there any harm to the patient or user? - Select -No harm to patient or userYes, both patient and user harmYes, patient harmYes, user harm Please provide a detailed description of the harm to the patient and/or user Did a second device complete the procedure successfully? Yes No Is the device in question available for return for investigation and analysis? Yes No 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 No 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 Shipping Details: Ship To Address Ship To Suite Number or Department Name Ship To City Ship To State AlabamaAlaskaAmerican SamoaArizonaArkansasArmed Forces (Canada, Europe, Africa, or Middle EastArmed Forces AmericasArmed Forces PacificCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFederate States of MicronesiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarshall IslandsMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPalauPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirgin IslandsVirginiaWashingtonWest VirginiaWisconsinWyoming Ship To Zip Code Ship To Country AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta and MelillaChadChileChinaChristmas IslandClipperton IslandCocos [Keeling] IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacau SAR ChinaMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar [Burma]NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaSão Tomé and PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Would you like a written response at the conclusion of the device complaint investigation? Yes No Submit
