Masimo Corporation - Customer Feedback Form

*Fields are required.

Request Type*

Device ID

Describe the issue in detail*

When was the event experienced?*

Not during monitoring	Out of box
During active monitoring	Unknown

Field is required

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

Yes

Unknown

N/A

Field is required

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?

Yes

N/A

Customer Information

Company

Contact First Name*

Field is required

Contact Last Name*

Field is required

Department

Occupation

Country*

Address

Address 2 (optional)

City*

Field is required

State/Province

Postal Code

Field is required

Email*

Field is required

Phone

Ext.

Person Submitting Feedback:

Same as above

Company

First Name*

Field is required

Last Name*

Field is required

Email*

Field is required

Field is required
Emails don't match!

Phone*

Ext.
Country code is required

Phone number is required

Is product being returned?*

Yes NoUnknownN/A Field is required

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 Field is required

Field is required
Masimo aware date cannot be before event date.

Select attachment file (optional)

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

Only jpg, gif, doc, docx, pdf, txt, xls, xlsx, and zip files are allowed!