Los Deline | Injectable Volumizing Implant

Incident Report

Please fill in form as fully as possible. Fields marked with * are required.

In case of emergency, Please contact the healthcare professional for medical advice or health concerns.
Los Deline can not provide specific medical advice or recommend any treatment over e-mail, by phone.
In order to assist our investigation, we may request consent to contact the healthcare professional who performed the procedure.

1. Name entity/person reporting of the incident(*)

Please type your full name.

2. Contact email(*)

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3. Serial number(s) and/or lot/batch number(s) of a product(*)

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4. Person who conducted a primary injection:

Doctor Name

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Clinic name(*)

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Doctor’s qualification

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5. Date of the procedure(*)

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6. Data of preoperative (before primary implantation) examination of the patient – medical history

Yes No Invalid Input

7. Has informed consent been signed?

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8. Diagnosis, Indications for use of the product in a particular patient

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9. Which zone was the product injected?(*)

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10. Volume injected

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11. What post-treatment recommendations were given to patient?

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12. Follow up visits data

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13. Incident description

Symptoms (complaints)

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Date of the first symptoms (complaints) manifestation

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Date of contacting the primary doctor after the onset of symptoms

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Diagnosis, first aid

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What examination was performed

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Information on the treatment actions taken by primary doctor

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14. Current state

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(*)

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