Submit a request

Please choose your issue below

Your email address

Select Affiliation with Prolaio

Internal or External Issue?

Internal to report issue on behalf of yourself or a Prolaio employee. External to report issue on behalf of a Patient

Enter Patient Name or Alias

Enter the Name/Organization of the Patient Sponsor(optional)

Enter the Patient ID Number(optional)

Enter the Patient Link to Clinical Software Profile(optional)

Enter Patient Email(optional)

Enter Patient Phone Number(optional)

Enter the User's Full Name(optional)

Enter your name if self-reporting an issue

Enter the User's Patient ID Number, if applicable(optional)

Enter the User's URL to the Clinical Software Profile, if applicable(optional)

Enter the User's Email Address(optional)

Enter the User's Phone Number(optional)

Select the Issue Type

Select the Device that is causing an Adverse Reaction or Injury

Enter the Device Type causing an Adverse Reaction or Injury

Adverse Reaction or Injury Type

Select the most serious adverse reaction or injury experienced by the user

Briefly Describe the Adverse Reaction or Injury Type

Was Medical Attention Required?

Was a hospitalization required?

Did a death result from the adverse reaction or injury?

Enter the Date or Approximate Date that the Adverse Reaction or Injury Occurred

Select the Product Category

Select the Biosensor Device Type

Enter the Biosensor Device Type(optional)

Select the VitalPatch Issue Category

Select "VitalPatch Issue Category not listed" if issue in not listed or unknown

Briefly Describe the Issue with the VitalPatch Overlay

Select the VitalPatch Overlay Issue Category(optional)

Select "VitalPatch Overlay Issue Category not listed" if issue not listed or unknown

Briefly Describe the Issue with the VitalPatch Overlay

Select the Indie Health BP Monitor Issue Category

Select "Indie Health BP Monitor Issue Category not listed" if issue in not listed or unknown

Briefly Describe the Issue with the Indie Health BP Monitor

Select the Indie Health Weight Scale Issue Category

Select "Indie Health Weight Scale Issue Category not listed" if issue in not listed or unknown

Briefly Describe the Issue with the Indie Health Weight Scale

Select the Corsano Issue Category

Select "Corsano Issue Category not listed" if issue in not listed or unknown

Briefly Describe the Issue with the Corsano Bracelet

Select the Carematix BP Monitor Issue Category

Select "Carematix BP Monitor Issue Category not listed" if issue in not listed or unknown

Briefly Describe the Issue with the Carematix BP Monitor

Enter the Date or Approximate Date that the Device Issue was Initially Discovered

Select the Cloud (CLOUD) Issue Category

Select "Cloud (CLOUD) Issue Category not listed" if issue in not listed or unknown

Briefly Describe the Issue with the Cloud (CLOUD) Services

Select the Cloud (CLOUD) Software Version

Enter the Current Cloud Version(optional)

Enter the Date or Approximate Date of the Cloud (CLOUD) Issue

Select the Patient Mobile App (PMA) Issue Category

Select "Patient Mobile App (PMA) Issue Category not listed" if issue in not listed or unknown

Briefly Describe the issue with the Patient Mobile App (PMA)

Enter the date or approximate date of the Patient Mobile App (PMA) Issue

Select the Clinical Software (PW & CLW) Issue Category

Select "Web: Clinical Software (PW & CLW) issue category not listed" if issue is not listed or unknown

Briefly Describe the Issue with the Web: Clinical Software (PW & CLW)

Enter the date or approximate date of the Clinical Software (PW & CLW) Issue

Clinical Software Type

Select the Clinical Software Type

Select the Portal Software Version(optional)

Enter the Current Portal Version Number

Select the Carelab Software Version(optional)

Enter the Current Carelab Version Number

Select the Workbench Software Version(optional)

Enter the Current Workbench Version Number

Enter the Clinical Software Type causing an Issue(optional)

Select the Order Type

Select the Order Device Type

Enter the Date or Approximate Date the Product Order was Placed

Select the New Order Issue Category

Select the Existing Order Issue Category

Select the Delivered Order Issue Category

Select Lost Product Device Type

Enter the Lost Product Device Type

Enter the Date or Approximate Date the Product was Lost

Is a Replacement Needed?(optional)

Select the Biosensor Device Type Associated with Issue, if Applicable(optional)

Select the biosensor that was in use when issue was observed, if applicable

Select the Biosensor Device UUID Type(optional)

Enter the Biosensor UUID Type(optional)

Enter the Biosensor UUID(optional)

Select the Mobile Device Type(optional)

Enter the Mobile Device Type causing an Issue

Select the Mobile Device Issue Category

Select "Mobile Device Issue Category not Listed" if your issue is not listed or unknown

Enter the Mobile Device IMEI(optional)

Select the Mobile App Version(optional)

Select the Mobile Device Operating System(optional)

Enter the Date or Approximate Date of the Mobile Device Issue

Description

Please provide any other details, as needed. If no other details are needed, please type N/A in the box. Please note: do not include any PHI (Protected Health Information) or PII (Personally Identifiable Information) in this field.

Attachments(optional)

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