Return Safety Form

Please fill in one form for each instrument you want to return.

Step 1: Please attach the completed Product Return Safety Form to the outside of the returned package.

Step 2: Ship to: RZ Medizintechnik GmbH / Unter Hasslen 20 / 78532 Tuttlingen

To insure the safety of our employees, we deny the receipt of deliveries without necessary documentation or without proper decontamination of the products.

Case number:


Contact Person

Email Address

Article Number


Additional markings on the product

Invoice Number

Date of invoice

Reason for return


Place of observation/default


* When and where did the defect occur? (name of hospital/ doctor etc.)

Detailed description of the defect:

Has the instrument been decontaminated?

If “yes,” state a brief description of the procedure (Autoclave, Cydex, etc..):

If “no”, the item will be returned!

The above mentioned device is free of harmful substances or has been decontaminated according to the safety regulations. The data in this product return form has been entirely completed and is true.




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