C

AC

504

MiS Implants Technologies Ltd.

MIS Forms
Document Type: Form
Customer Complaint Report
Document Name:
Marketin8
Sub Department: Marketing
Department:
D7.2.2-1
Revision: 1.0 Inception: 30/12/2015
Procedure Number:

Customer Complaint Report Form

CHRE PHAMA DIS1a13UToPS
Distributor's Name:
Customer's Name (reported by): DR.pPIYAVLA Date of complaint report: 5/oz/2622
Product's catalog Ne: MfA 1335 Product's description:w18o123{(315*1
Lot Number:w1fo11463 Order Ne:

Date of event:. Quantity:

Type of nonconformity: Téchnical Functional Visual Other
Complaint's details (please give as much details as possible):

Mi SfMen

Is this the first complaint/incident with this product/patient? es O No Unknown

If "No" please describe other occurrences:

Prodycts involved (including device name and its lot number):

plant:3:25A13- MFHISAS O Abutment/healing cap:
Bone GraftMaterial/Membrane:.
OAdapter/Key: O Other:

Torque control device used: Ges No ON/A Torque applied:_0Ncm

Disinfectant used: 1 6 (type)- ONo O N/A
e
Sterilization method (please elaborate): pon ONo ON/A
Detergent used: O Yes (type)Anho(ane ONo ONJA

IMPORTANT as close as possible to the

-
Customer complaints should be reported incident's occurrence date.
- Please attach all thee devices involved.
- Product must be sterilized and disinfected prior to shipping.
- We are interested in comprehensive investigation of received complaints therefore,
submission of completely fulfilled form is kindly appreciated.

Page 1 of 1
 SHREE PHARMA, DISTRIBUTORS
DISTRIBUTORS FOR MIS IMPLANT- TAMIL NADU
SALES OFFICE:- NO:18, ALANGATHA
STREET,TRIPLCANE, CHENNAI-600005
REGD. OFFICE PLOT NO.48, 4/37 S1 (EAST FACING PORTION) 2ND FLOOR,SWAMINADHAN 4lH STREET, KOTTIVAKKAM, CHENNAI-600041
GST No:33AAUFS8559A1ZT DL Number: 6048/MIII/20B, 5918/MIIV21E PAN NO.
AAUrs8559A, FSSAI No :22419070000669 PH:044-43012044
|To 203045
Terms Bill No &Page No Bill Date Tax Invoice
DR.PRIYANKA7 DP-DP BILL DP01000083 1/1
30/10/2021 7
11B, MANGALI NAGAR 1st STREET Order Date Due Date
Salesman Name Salesrep
ARUMBAKKAM 10/30/2021 30/10/21 DENTSPLY INDIA PVT |R.S
CHENNAI 600 106 GSTIN DLNo PAN No FSSAI No
TAMILNADU TNDC-REG-NO. 26287
S. Description & Packing Alt.Code HSN/ Batch Exp Qty Free Sale Price
No SAC
MRP CCSTUGST| SGST Total
No. %
MAIN PRODUCTS
SEVEN IMPLANT DIA 3.75 L 13MM 1'S M-F713375s 90212900|wi8011763 10/23
4910.71 13600.00 6% 294.64| 6% 294.64 5500.00
SEVEN IMPLANT DIA 4.20 L 13MM 1'S M-F713420 90184900 W1 8009409 07/23 13600.00 6%
4910.71 294.64| 6% 2946 5500.00
SEVEN IMPLANT DIA 5 L 13MM
3 S
M-F713500 90184900 w21021659 05/26
4910.71 13600.006% 294.64 6% 294.64 5500.00
STANDARD CEMENTING POST 1'S DMACI0 90184900 W18010153 0 1030.00 3410.00 6% 123.60 6% 123.6 2307.20
M-
wDE PLATFORM EMENTIG POST 'S wMAC1090184900 Wi8008132 0
1030.00| 3410.00 5 % 61.80 6% 61.80 1153.6

ITEMS: 5 QTY: 6 BASE: 17822.13 SGST : 1069.33 CGST: 1069.3278 GST 2138.66 AMOUNT
Category Base Gst Amount
TCS Calculate@
-

19960 79

GST_12% 17822.13 2138.66 9960.7

CR
PD .00 CD
Rounded Net Amount| 19961.00

|Remarks
uount in Words: Rupees Nineteen Thousand Nine
Hundred And Sixty One Only
E.&0.E
SE-Wondersof(Ph:044-42073411) forSHREE PHARMA DISTRIBUTORSs