Report Product Issue (Feedback & Complaints)
Please Identify yourself, the band ID, date of the issue, any clinical corrective action taken.
Email address *
Clinic ID & Location [XXX - City] *
Clinician Name
Band ID# *
Primary Issue *
Describe Product Problem *
Cause of Problem
Photos (please provide 3 angles)
Corrective Action Taken at Clinic
Requested Response from HeadStart *
Was there an injury?
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