Field Evaluation Form

Contact Information

* Contact Person:
* Phone:
* email:

Description of Complaint

* Date of Incident:
* Incident Location and Address:
* Surgeon's Name:
* Surgeon's Phone Number:
* Description of Incident:
* Product Line:
Set Number:
* Part Description:
Part Number:
Lot Number:
Donor Id (Tissue)-if applicable:
Quantity:

Patient Information

Was a patient involved?
  
Patient Approximate Age:
Patient Gender:
Does the incident involve the death of the patient?
  
Does the incident involve an implant/graft that is still in the patient?
  
Is the incident life threatening?
  
Will the patient need additional surgery as a result of the incident?
  

Return Information

Will device be returned to Alphatec Spine? (if yes, RMA is required)
  
* Returned Materials Authorization (RMA) Number (Obtain from Physician Services):
 
* Required Fields