Customer Complaint Form – Fertility

Our priority is customer satisfaction.

Customer Complaint Form – Fertility

CooperSurgical is committed to delivering evidence-based, customized solutions comprising high quality, innovative products to optimize a fertility clinic’s outcomes. As a global medical fertility product manufacturer and genomics services provider, it is imperative that we deliver safe, effective and reliable products and services to our customers. Submitting your feedback to CooperSurgical drives us to exceed customer service and product expectations.

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Date of this Report

DD slash MM slash YYYY

Details of the IVF Professional Reporting the incident

Name of IVF Professional Reporting Incident*

First Last

Email of IVF Professional Reporting Incident*

Telephone/Mobile Name of IVF Professional Reporting Incident

IVF Clinic/Company Name*

Full Address (Street, Building, Zip Code)

Country*

Customer Type*

Your CooperSurgical account number*

Product Details

Product Type*

Catheter Incident Type*

Please Specify*

Please note: the more information you can provide us with, the more it helps us to understand your reported incident.

When did you notice this?*

At loading

During embryo transfer

After embryo transfer with retained embryo

Please describe what happened during your embryo transfer catheter loading experience or procedure

Do you pre-warm the catheter prior to use?*

Yes

If Yes, please provide details how you pre-warm the catheter prior to use

What type of media do you use for embryo loading?

Do you pre-rinse the catheter?*

Yes

What type of media do you use for rinsing the catheter?*

Do you load embryos from drops under an oil overlay?*

Yes

Please specify the name of the oil

Do you load air bubbles either side of the embryo?*

Yes

Please describe how you load your catheters

Which performance indicators were affected? (Tick all relevant)

Fertilisation rate (2PN as % injected/inseminated)

Cleavage rate

Development on day 3 (% at 7-9 cells)

Development on day 5 (% reaching blastocyst)

Utilisation rate (2PNs transferred or frozen)

Alternatively, have you observed problems with other features of embryo development eg. fragmentation?

Yes

If so, please give details and supporting data:

Incident Details

Type of Incident*

Broken or damaged item

Mislabelled Product

Shipping Damage / Package Damage

Debris within product or package

Product performance

Missing item / wrong item delivered

Other

If Other Please Specify*

Report More

Are you reporting more than 3 different item codes?

Yes

Please upload documentation with all the Item Codes, including the Product Type, Item Batch, Quantity(e.g boxes, bottles…) and Invoice Numbers

Maximum file size 25MB. File Formats Allowed: pdf, txt, docx, doc, rtf, xls, xlsx, jpg, jpeg

Drop files here or

Accepted file types: pdf, txt, docx, doc, rtf, xls, xlsx, jpg, jpeg, Max. file size: 25 MB, Max. files: 5.

Cycles

Number of Cycles

Comments

Oocytes

Number of Oocytes

Comments

Day 2 Embryos

Number of Day 2 Embryos

Comments

Day 3 Embryos

Number of Day 3 Embryos

Comments

Day 5 Blastocysts

Number of Day 5 Blastocysts

Comments

Item Code*

Item Batch*

Quantity (e.g boxes, bottles…)*

Coopersurgical Invoice/s number*

Providing the invoice number will expedite the credit process

Product Type*

Add Another item

Add another Item

Item Code*

Item Batch*

Quantity (e.g boxes, bottles…)*

Coopersurgical Invoice/s number*

Providing the invoice number will expedite the credit process

Product Type*

Item Code*

Item Batch*

Quantity (e.g boxes, bottles…)*

Coopersurgical Invoice/s number*

Providing the invoice number will expedite the credit process

Add Another item

Add another Item

Please provide details about the reported incident:*

Please provide as much detail as possible, the more detail we have will help us to understand and prioritise the complaint accordingly.

Type of Procedure*

Were additional steps needed to complete the procedure?*

Yes

If yes, what were they?

Date of Procedure/Incident

MM slash DD slash YYYY

Any patient injury or impact to the gamete or embryo?*

Yes

If Yes, please explain*

Was a Medical or Procedural Intervention Required?*

Yes

If Yes, please explain*

Current status of the Patient/Gamete/Embryo

Please upload any videos, photos or other evidence about the reported events here

Drop files here or

Accepted file types: jpg, jpeg, pdf, mp4, Max. file size: 25 MB, Max. files: 5.

Products to be returned?*

To enable us to complete a thorough investigation we require the products returned where possible.

Yes

If No, please explain why no product is being returned*

Additional Information

Do you require a return investigation letter for your complaint?*

Yes

For official CooperSurgical use only

Are you completing this form on behalf of your customer?

Yes

Name*

First Last

Form Completed By:*

Phone*

Address*

Comments

This field is for validation purposes and should be left unchanged.