Please provide the information requested below when submitting your product feedback.

Areas indicated with an asterisk (*) are required data entry fields and must be completed to submit this form.

Submitter First Name *

Submitter Last Name *

Submitter Email Address *

Submitter Phone Number *

Submitter Country *

Customer Contact Name

Customer First Name *

Customer Last Name *

Customer Email *

Customer Phone *

Company Name *

Company Address *

Suite Number or Department Name

Country *

City/Town *

State/Province *

Zip/Postal Code *

Name of your Hologic Sales Representative

Please provide a detailed description of the issue *

Select a Product *

NovaSure Components * NovaSure ClassicNovaSure ADVANCEDRFC10 Controller

MyoSure Compnents * MyoSure REACHMyoSure MANUALMyoSure LITEMyoSure XLMyoSure HysteroscopeMyoSure Controller

Lot Number *

Provide Number *

Serial Number *

Quantity of product possibly defective *

Was there any harm to the patient or user? *

Did a second device complete the procedure success * YesNo

Is the device in question available for return for * YesNo

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