INCIDENT REPORTING

Please describe the incident, listing xact^TM IOL Model and serial number,
Surgeon’s name and the name and address of the hospital/clinic where the incident
occurred; the date of the incident; patient condition; indicate whether
secondary surgical intervention was needed and whether the IOL was
explanted.

Description of Incident:

Patient Condition (required):

Was secondary surgical intervention needed? YesNo

Date of the incident:

Identification of the IOL involved
Model:
Serial #:

Surgeon's Name:

Address of the hospital/clinic:

Reporter contact information:
Name:
Email: