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Incident QuestionnaireJonathan Gilbrook2024-04-19T14:10:19+00:00

Incident/Pre Service Questionnaire Form

"*" indicates required fields

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You must be directed here by a seeded link provided by customer services.
Please contact customer services on:
Tel: 01252 344 007
Email: enquiries@welmedical.com

Incident Information

Is this part of a software update?
DD slash MM slash YYYY
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Who was the operator of the defibrillator at the time of incident?*

Has the device ever been used before in an event?*
In previous events, did the device operate as you would expect?

Patient Information

What is the gender of the patient, if applicable

Healthcare Facility Information

Address of the facility

Device Information

DD slash MM slash YYYY
Was the device stored outside?
This could include a defib cabinet, in a vehicle or non-heated building.
This information helps us identify a potential issue with your cabinet, which could cause your defibrillator to have issues.
Has the device been stored with the battery fitted and in ‘operating mode’?
Are pads fitted to the device?
What symbol is displayed in the screen?
What is the current battery level?
What is the pad level?
Is the LED flashing? If so, what colour?
You can find out your software version by holding the 'i' button down on your device. It will say: "Software version..."

By confirming your agreement to receive a loan unit, you accept full responsibility for returning the following serialized items*:

  • Carry Case
  • Battery
  • One (1) Set of Electrode Pads
  • Defibrillator

*Please note that all items have been serialized for tracking purposes, and we expect the original items provided to be returned to WEL Medical upon collection of the loan unit. Failure to return any of these items may result in additional charges.

Delivery Address*
Please enter the address of where we need to send the loan device.
Pick-Up Address
Please enter the address of where we can pick up the loan device when investigations/repairs are complete.
We will use this email to send tracking information regarding your loan device.

Faulty Device

Please enter the pick up and return address of your faulty device. We can only pick up from domestic and business addresses. Courier services will not collect from cabinets.
Pick-Up Address
Please enter the address where we can pick up your device.
Return Address*
Please enter the address of where we need to return your device
We will use this email to send tracking information regarding your faulty device.
DD slash MM slash YYYY
Select a suitable date for us to collect your device.
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(Please list all items and their serial numbers sent with unit - this includes any leads, batteries, adaptors, electrodes etc.)

Consumables & Accessories

It is important that we receive back any consumables and accessories that were supplied with your device. This includes batteries and electrode pads. Failure to include these may result in your case being delayed.
Additional Items
Product Name
Serial Number (if applicable)
Expiry Date (if applicable)
 
(Please list all items and their serial numbers sent with unit - this includes any leads, batteries, adaptors, electrodes etc.)

Your Details

Name*

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Our Address

1 Chancerygate Way
Farnborough, Hants.
GU14 8FF
01252 344 007

enquiries@welmedical.com

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