STRAUMANN® GUARANTEE
Dental Implant System
CUSTOMER INFORMATION
Sales Name
*
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Please select Sales Name.
Email
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Telephone
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Max 10 Characters
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Clinician's Name
*
Max 60 Characters
Please enter Clinician's Name.
Customer Account #
Max 32 Characters
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Workplace Address
*
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Country
*
Select
Thailand
Please select Country.
COMPLAINT
Implant
Preview .PDF
1. SELECT COMPLAINTS
Please select.
Implant Complaints
Abutment or Restoration Complaints
Instuments Complaints
2. PRODUCT INFORMATION
(Please list all involved Straumann Products)
Please enter.
Lifetime Plus claims must be accompanied by the restoration and restoration details (include here).
Item 1
Article Number
Max 20 Chars
Please enter Article Number.
LOT Number
Max 10 Chars
Please enter LOT Number.
Placement Date (D/M/Y)
Please enter Placement Date.
Removal/Event Date (D/M/Y)
Please enter Removal/Event Date.
Regio
#
Please enter Regio.
Item 2
Article Number
Max 20 Chars
Please enter Article Number.
LOT Number
Max 10 Chars
Please enter LOT Number.
Placement Date (D/M/Y)
Please enter Placement Date.
Removal/Event Date (D/M/Y)
Please enter Removal/Event Date.
Regio
#
Please enter Regio.
Item 3
Article Number
Max 20 Chars
Please enter Article Number.
LOT Number
Max 10 Chars
Please enter LOT Number.
Placement Date (D/M/Y)
Please enter Placement Date.
Removal/Event Date (D/M/Y)
Please enter Removal/Event Date.
Regio
#
Please enter Regio.
Item 4
Article Number
Max 20 Chars
Please enter Article Number.
LOT Number
Max 10 Chars
Please enter LOT Number.
Placement Date (D/M/Y)
Please enter Placement Date.
Removal/Event Date (D/M/Y)
Please enter Removal/Event Date.
Regio
#
Please enter Regio.
* Maximum 4 items.
3.GENERAL PATIENT INFORMATION
(Only required with implant complaints)
Patient ID No
*
Age
*
Gender
*
Female
Male
*For data privacy reasons DO NOT insert patient's name
Medical Record:
*
No
Yes
Please check
Diabetes Mellitus
Psychological disorder
Uncontrolled endocrine illness
Radiation Tx-head/neck area
Xerostomia
Compromised immuno resistance
Illness requiring steroids
Lymphatic disorder
Blood coagulation disorder
Chemotherapy around time of implant placement
Drug or alcohol abuse
Allergies
(Optional)
Other local or systemic diseases which may be significant:
(Optional)
Does the patient smoke?
*
Yes
No
No significant findings
4. SURGICAL INFORMATION
*
(Only required with implant complaints)
Manual placement
Handpiece adapter
If implant was placed and removed the same day, was another implant successfully placed in the site during surgery?
*
Yes
No
If you experienced difficulty with inserting device/pre-mounted transfer part this occurred upon:
*
No
Yes
Please check
Implant insertion into bone
Removal of device from implant
Removal of implant from vial
Other
At the time of surgery, were any of the following present:
*
No
Yes
Please check
Periodontal disease
Diseased mucous membrane
Local infection/subacute chronic osteitis
Complication in site preparation
Bone quality
*
TypeI
Type II
Type III
Type IV
Was the site tapped?
*
Yes
No
N/A
Bone Level Profile Drill used?
*
Yes
No
N/A
Tisue Level Profile Drill used?
*
Yes
No
N/A
Holding Key used
*
Yes
No
N/A
Was primary stability achieved?
*
Yes
No
Did implant achieve osseointegration?
*
Yes
No
Was the implant surface completely covered with bone?
*
Yes
No
Was augmentation performed at the time of surgery?
*
No
Sinus
Ridge
Material used
Was GTR membrane used?
*
No
Yes
Resorbable
Non-resorbable
Material used
5. EVENT INFORMATION
(Only required with implant complaints)
Hygiene around implant
*
Excellent
Good
Fair
Poor
Were any of the following involved in the event?
*
No
Yes
Please check
Trauma/Accident
Biomechanical overload
Immediate extraction site
Adjacent to endodontic tooth
Tongue (pressure)
Implant fracture
Overheating of bone
Peri-implantitis
Infection
Bruxism
Inadequate bone quality/quantity
Previous bone augmentation
Nerve encroachment
Sinus perforation
Bone resorption
Other
At the time of implant failure, there was (check all that apply)
*
No
Yes
Please check
Pain
Mobility
Hypersensitivity
Bleeding
Fistula
Increased sensiivity
Swelling
Asymptomatic
Abscess
Numbness
Inflammation
Other
Was the prosthesis fitted?
*
No
Yes
If yes, please complete section 6.
If the implant is not being removed, is there evidence of the following (check all that apply)?
*
No
Yes
Please check
Extent (mm): Bone Loss
Dehiscence
Peri-implantitis
Fenestration
Other
Please comment on why you think the implant failed/was removed:
*
6. PROSTHESIS INFORMATION
(Only required for abutment and restoration complaints)
Select
*
Model
Insertion
In use
Type of restoration?
*
Crown
Bridge
RPD (upper)
RPD (lower)
Full (upper)
Full (lower)
Other
Temporary :
Date of temporary restoration installation
Final :
Date of final restoration installation
Date of abutment removal (D/M/Y)
*
Torque Control Device used?
*
Yes
No
Unknown
Was the recall appointment schedule followed
*
Yes
No
Torque applied
*
Description of event:
*
7. INSTRUMENTS
(Only required for instrument complaints)
Approximate number of uses: (Cutting instruments only)
*
initial use
2–5
6–10
10–15
more than 15
Type of cleaning method used
*
Manual
Ultrasonic
Thermodisinfection
Other
Type of sterilization method used
*
Autoclave
Dry heat
Chemiclave
Short description of incident:
*
Please return questionnaire, autoclaved product and include X-rays (as appropriate).
Use a padded package to return items – failure to do so could result in items lost during shipment and void guarantee program. Autoclave
all products and label them as
sterile
. Based on the Straumann Guarantee Terms and Conditions, please consider replacing the above listed products.
Please note that your data will be transferred to Institut Straumann AG, Basel, Switzerland but may also be transferred for further investigations to the countries where the respective manufacturer of the product is domiciled. This may include countries outside the European Union for which there is no European Commission decision that they ensure an adequate level of protection for personal data.
Doctor's Signature:
*
Please sign in the box above.
reset
Date:
03/01/2025
For internal use only
CSN
PSO
ASR
RPC
Info incomplete
Std/No
Submit completed
Thank You
Your reference number
Claim-2024-921-00001
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