Brand Name | RESHAPE INTEGRATED DUAL BALLOON SYSTEM |
Type of Device | INTRAGASTRIC BALLOON |
Manufacturer (Section D) |
RESHAPE MEDICAL INC. |
100 calle iglesia |
san clemente CA 92672 7502 |
|
Manufacturer (Section G) |
RESHAPE MEDICAL INC. |
100 calle iglesia |
|
san clemente CA 92672 7502 |
|
Manufacturer Contact |
lisa
maloney
|
100 calle iglesia |
san clemente, CA 92672-7502
|
9494296680
|
|
MDR Report Key | 7022771 |
MDR Text Key | 91801483 |
Report Number | 3007934906-2017-00035 |
Device Sequence Number | 1 |
Product Code |
LTI
|
UDI-Device Identifier | B001RSM1011 |
UDI-Public | B001RSM1011 |
Combination Product (y/n) | N |
Reporter Country Code | US |
PMA/PMN Number | P140012 |
Number of Events Reported | 1 |
Summary Report (Y/N) | N |
Report Source |
Manufacturer
|
Source Type |
health professional |
Reporter Occupation |
Physician
|
Type of Report
| Initial |
Report Date |
11/02/2017 |
1 Device was Involved in the Event |
|
1 Patient was Involved in the Event |
|
Is this an Adverse Event Report? |
Yes
|
Is this a Product Problem Report? |
No
|
Device Operator |
Physician
|
Device Model Number | 01-0011-001 |
Device Catalogue Number | RSM101 |
Was Device Available for Evaluation? |
No
|
Is the Reporter a Health Professional? |
Yes
|
Was the Report Sent to FDA? |
No
|
Initial Date Manufacturer Received |
10/11/2017
|
Initial Date FDA Received | 11/10/2017 |
Was Device Evaluated by Manufacturer? |
Device Not Returned to Manufacturer
|
Is the Device Single Use? |
Yes
|
Is This a Reprocessed and Reused Single-Use Device? |
No
|
Type of Device Usage |
Initial
|
Patient Sequence Number | 1 |
Patient Outcome(s) |
Required Intervention;
|
Patient Age | 47 YR |