Incident Reporting

This form is intended to help you report quickly to BII any
problem occuring with SwayStar™.
1. Was the problem related to :
Test Subject (Patient)
2. Please describe carefully the problem :
3. Did you report the problem to your local Representative ?
Yes No
4. Your SwayStar™ serial number is :
5. Your E-Mail address is :
6. Confirm your E-Mail address:
Security Code
7. Confirm security code:

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