Customer Support | OrthoGrid Systems, Inc.

Title of Submission *

Reporter Name *

First Last

Facility Name *

Facility Address

Street Address Address Line 2 City State/Region/Province Postal / Zip Code Country

Reporter Phone Number

Code Number

Reporter Email

Physician User Name

First Last

Physician Email

Date of Use *

MM/dd/yyyy

Part Number

Lot / Serial Number

Software Version

Software Version can be found on the home screen after device to powered on.

C-Arm Information

Make and Model

Event Description: *

Upload Images

Upload Files

Upload videos files or document files here.

Explain answer in the section:

If death or serious impairment occurred, call our Quality Department immediately. If surgery was delayed provide information on the impact to the patient.

Event Resolution:

How was the problem solved? Was another device used?

Patient Sex

Patient Age

Status of Ticket *