Northeast Scientific Inc. Defective Device Return Form


Please complete this form to initiate a defective device return. 

A Clinical Sales Representative will contact you within 24 hours to gather further information.
 

Required FieldDescribe Defect 
Required FieldAdditional Customer Comments 

 Company Information
Required FieldCompany Name / Account Number 
Required FieldAddress line 1 
Address line 2 
Required FieldState 
Required FieldZip/Postal Code 

 Reported By
Required FieldFirst Name 
Required FieldLast Name 
Required FieldPhone Number 
Required FieldEmail 

 Failed/Defective Device Info
Required FieldCase Type 
Required FieldDate of Incident Pick
Required FieldSupport Item 
Other Item (Not Listed) 
Required FieldSerial/Lot Number 
Required FieldSpecific Defect 
If other or if more detail is needed; please describe fully 
Required FieldWhen did the defect occur? 
Required FieldDid the defect result in patient impact? 
Required FieldIf there was patient impact, what type? 
Required FieldIf IVUS, which system was used? 
If Other, specify which system was used 
Required FieldIf IVUS, what troubleshooting was performed? 

After this form has been submitted you will receive an e-mail that includes your assigned case number.

Please write this case number on the device before it is sent back to:

Northeast Scientific Inc., 2142 Thomaston Ave., Waterbury, CT 06704