Intake Form
KeborMed Product(s) name:
Please enter Product
Complainant:
Please enter Name / Surname
KeborMed Product(s) Identification: (Eg: Software version number)
Please enter the identification
Complainant phone number:
✓ Valid
Invalid number
Date of complaint:
Please enter the date
Complainant email address:
Please enter a valid email address
Date of Complaint observation:
Complaint received via:
Please enter receiver
KeborMed Product User Contact Information (if different from Complainant):
✓ Valid
Invalid number
Please enter domain
Submit Form
