Name

First Name

Last Name

Test Used

Corona Gold IgG

Other

Type of Problem:

The test did not work as expected

The user experienced a health problem or other adverse event

Was the Problem:

Mild

Moderate

Severe

If the problem was related to the test, it would help us to know the lot number printed on the outside of the carton. [we will need to add a picture as example] Do you wish to be contacted about the problem? Please note that we will contact you only if justified after an internal analysis.

Yes

No

Are you based in the USA:

Yes

No