Customer Feedback Form

Philips offers a robust portfolio of Healthcare Solutions. The goal of each product is clear -- faster and more accurate diagnosis and treatment. Our product line includes X-ray, ultrasound, magnetic resonance, computed tomography, nuclear medicine, PET, radiation oncology systems, patient monitoring, information management, resuscitation products, and medical supplies. To provide product feedback, please complete the following form.

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PERSONAL INFORMATION

* Salutation	Professor Doctor Mr. Mrs. Ms
* First Name
*Last Name
*Position/Title
*Company/Institution
*Address
Address 2
*City
*State
*Post/Zip
*Country
*Telephone
*Email

QUESTIONS

1. Please provide the following information. Product/Model Number.

2. Serial number.

3. Lot number.

4. Sales Order Number.

5. Revision Number.

6. Is the product/device operating properly?

7. If you answered 'no' to question 6, please explain.

8. Is the product/device being used correctly (according to the Instructions for Use)?

9. If you answered 'no' to question 8, please explain.

* 10. Is acknowledgement of feedback required?

11. Comments:

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