Complaint Notification

- COMPLAINT PRESENTED BY
- Who?*
  - Dr.
  - Distributor
  - Other
- Name*
- Address*
- Country*
- Email*
- Phone*
- INFORMATION CONCERNING THE PRODUCT
- Product’s name*
- Lot number*
- Quantity*
- Purchased from*
- Date*
  MM slash DD slash YYYY
COMPLAINT INFORMATION
Date when the complaint is detected :*
MM slash DD slash YYYY
Classification:*
- Product does not meet the quality specifications
- Product does not meet its presentation or integrity specifications
- Other
Other
Complaint description narrative:*
You deliver the (rest of the) product to Skin Tech Pharma Group S.L.:*
- No
- Yes
Why not?*
Please describe what you will deliver (quantity of product, state & condition of the product, etc.)*
Additional information:*
Max. file size: 25 MB.
Add in the present incident notification evidences (images, medical part, etc.) that the patient suffered
Data protection: In order to comply with Regulation (EU) 2016/679 General Data Protection, we are obligated to inform you the following: The person responsible for processing your data is Skin Tech Pharma Group, S.L., with CIF: B17470261 and address at C/ Pla de l’Estany, 29, 17486 – Castelló d’Empúries (Spain). At Skin Tech Pharma Group, S.L. we only process your data in order to carry out the necessary inquiries in relation to your complaint and/or incident notification. The personal data provided will be kept as long as it is not requested by the interested party, and always respecting the minimum periods established in Law 21/2000, of 29 December, on the rights of information concerning the health and autonomy of the patient and clinical documentation, of the Generalitat de Catalunya. You have the right to access to your personal data, as well as to request the rectification of inaccurate data or, where appropriate, request its deletion when, among other reasons, the data are no longer necessary for the purposes for which they were collected. In certain circumstances, you will have the right to request limitation of the processing of your data, in which case they will only be kept for the exercise or defence of claims. In certain circumstances and for reasons related to your particular situation, you will have the right to object to the processing of your data. Skin Tech Pharma Group, S.L. will no longer process your data, except for compelling legitimate reasons, or for the exercise or defence of possible claims. The legal basis for the processing of your data is your consent given at the end of this document, so the refusal to process data or the exercise of the right of opposition would necessarily lead to the end of the relationship and/or processing. Right of Image: In accordance with applicable law of Intimacy and Own Image, I expressly consent to Skin Tech Pharma Group, S.L. to use my image and keep the photographs I have provided within the framework of the enquiries arising from my complaint and/or notification of incident. By signing this document, I give my consent to Skin Tech Pharma Group SL to process my personal data and the right of image in the above terms.
Date*
MM slash DD slash YYYY
*
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Complaint Notification

COMPLAINT PRESENTED BY

INFORMATION CONCERNING THE PRODUCT

COMPLAINT INFORMATION