Safety Incident Report Form

If you have observed any irregularities or issues regarding the use of a Meden-Inmed product, please complete this form. Your incident report helps us address problems promptly and improve the quality and safety of our products. Please fill out the form carefully so that we can take appropriate action as quickly as possible. All incident reports are handled with the utmost seriousness.

This incident report may concern:

Damage or malfunction of the product
Safety concerns related to product use
Any adverse reactions or health problems associated with the product

Please include any details that may help resolve the issue (e.g., photos of the damage, copies of invoices, medical documents, etc.).

1. Contact Details of the Person Submitting the Report:

Full Name *
Email Address *

Telephone Number

Preferred Contact MethodEmailTelephone

2. Product Details:

Product Name *
Serial Number or ID *
Date of Purchase *

3. Description of the Incident/Complaint:

Detailed Description of the Problem *
Was the problem life-threatening?NoYes

Nature of the ProblemProduct functionInstructionsOther aspect

4. Attachments:

Please attach any files that may help with the report (e.g., a photo of the damage, proof of purchase, or a document illustrating the problem).
Allowed file formats: *.jpg, *.png, *.jpeg.
Maximum file size: 5 MB.

Select fileNo file selected

5. Personal Data Protection:

The administrators of your personal data are Meden‑Inmed sp. z o.o. with its registered office in Koszalin and Technomex sp. z o.o. with its registered office in Gliwice – as joint controllers. Your personal data will be processed for the purpose of sending commercial information regarding products and services offered by the joint controllers – to the extent of the communication channels for which consent has been given (email / SMS / phone). The legal basis for data processing is your prior consent (Article 6(1)(a) of the GDPR) in conjunction with the provisions of the Polish Act on Electronic Communications. The joint controllers have entered into a joint controllership agreement (Article 26 of the GDPR). The essential content of the arrangements is available upon request. Consent is voluntary and may be withdrawn at any time – separately for each communication channel. You have the right to access your data, rectify it, delete it, restrict its processing, transfer your data, and lodge a complaint with the President of the Personal Data Protection Office (UODO). More information can be found in the privacy policies of: Privacy Policy and Technomex.

I have read the Privacy Policy *

6. Confirmation of Notification:

I confirm that the information provided is true. *

* Required field

Updated: 27-02-2025, 08:33