Customer Feedback Form

Feedback – Completed by individual receiving the information

  • Received By

  • Date Received

  • Customer Contact Name

  • Customer Phone number

  • Customer Email

  • Customer Facility name

  • Customer Address

USA Device(s) Affected (Hold Control to select multiple devices)

  • Skylife Products
    • Skylife System Hospital (SKY-HOS)
    • Skylife System Home (SKY-HOM)
    • Cloud Cover (CC)
    • CloudCover Plus (CCP)
    • GelMat (SKY-GEL)
    • Control Unit & Power Supply (SKY-CON)
    • Light Module (SKY-LIM)
    • Eye Protection (EP1X)
  • International Skylife Products
    • Skylife System with Travel Case (SKY-HOCA)
    • Skylife System Hospital (SKY-HOSI)
    • Skylife System Home (SKY-HOMI)
  • ICON Products
    • Phoenix ICON™ Cart (PCI 40-1001)
    • Phoenix ICON™ GO System (PCI 40-2001)
    • Camera Hand Piece (PCI 40-1002)
    • Phoenix CONNECT (PCI 40-3000)
    • Fluorescein Module (PCI 40-1004)

  • ICON Products

    • PAL (PAL-HOS)
    • PAL Disposable Sensor (PDS-10)

  • Description of Feedback

  • Patient Involved? Select one...

    • Yes
    • No

  • Injury or Death? Select one...

    • None
    • Injury
    • Death

  • Device to be Returned? Select one...

    • Yes
    • No

Thank you! Your submission has been received!

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Form QA-711.1FM Rev D