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Incident questionnaire

Repair Consignment Note

Location(*)

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Customer number (*)

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Name/company (*)

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Contact person(*)

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Street/Number(*)

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Zip code / residence(*)

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Phone number(*)

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E-mail(*)

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Please indicate alternative billing address if needed

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Problem description(*)

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Product / serial number(*)

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Date of Purchase(*)

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Delivery note number / bill number

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Please enclose a copy of the delivery note or bill in case of expected warranty repair.

Attachments

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Please check(*)

We agree that Nouvag Dental-und Medizintechnik GmbH provides our e-mail address to DHL or any other logistics provider to track the shipment via tracking number.

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Agree(*)

We agree that Nouvag AG provides our e-mail address to TNT or any other logistics provider to track the shipment via tracking number.

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For the protection of our employees only cleaned and sterilized articles can be accepted if they have been in contact with body fluids. In case of missing certification, we reserve the right to reject the article or decontaminate the article at extra costs.

Pease Check(*)

We herewith certify, that the above article has been properly cleaned / decontaminated.

Pplease accept checkbox

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Nouvag AG
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St. Gallerstrasse 25
9403 Goldach
Switzerland

Client-No.(*)

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Name/company(*)

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Contact person(*)

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Street/Number(*)

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Zip code /residence(*)

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Phone number(*)

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E-mail(*)

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Other information

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Product /serial number(*)

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Date of purchase(*)

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For the protection of our employees only cleaned and sterilized articles can be accepted if they have been in contact with body fluids.

In case of missing certification, we reserve the right to reject the article or decontaminate the article at extra costs.

Please check(*)

We herewith certify, that the above article has been properly cleaned / decontaminated.

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Incident questionnaire

Details of the product

Details of the creator of the complaint

Details of the complaint incident

Repair Consignment Note

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