Masimo Corporation - Customer Feedback Form

*Fields are required.

Request Type*

Device ID

Describe the issue in detail*

When was the event experienced?*

Not during monitoringOut of box
During active monitoringUnknown

Did the device provide an alarm or display an error message?*

YesNoUnknownN/A

Is the device connected to a Central Monitoring System such as Patient SafetyNet, Iris Gateway, or DCX?

Yes No

N/A (does not apply to sensors, cables, or accessories)

Does the device require any additional parameters (check all that apply)?

Total Hemoglobin (SpHb^®)
Pleth Variability Index (PVi^®)
Carboxyhemoglobin (SpCO^™)
Methemoglobin (SpMet^®)
Oxygen Content (SpOC)
Acoustic Respiration (RRa^®)
Respiration Rate from the Pleth (RRP^®)

Was the sensor or cable used in conjunction with a Philips monitor?

YesNoN/A

Customer Information

Company

Contact First Name*

Contact Last Name*

Department

Occupation

Country*

Address

Address 2 (optional)

City*

State/Province

Postal Code

Email*

Phone

Ext.

Person Submitting Feedback:

Same as above

Company

First Name*

Last Name*

Email*

Phone*

Ext.

Is product being returned?*

Yes NoUnknownN/A

Tracking Number (if available) Product #1
Model Name/Product (if available)
Part Number (if available)
Serial Number (if available)
LOT Number (if available)
Quantity

Tracking Number Product #2
Model Name/Product
Part Number
Serial Number
LOT Number
Quantity

Tracking Number Product #3
Model Name/Product
Part Number
Serial Number
LOT Number
Quantity

Tracking Number Product #4
Model Name/Product
Part Number
Serial Number
LOT Number
Quantity

Tracking Number Product #5
Model Name/Product
Part Number
Serial Number
LOT Number
Quantity

Was there any impact to a patient, user, or other person?*

YesNoUnknown

Select attachment file (optional)

Max file size is 25MB
If submitting multiple files, please upload them as a single .ZIP file.