Location and Physician

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* 1. Hospital Name

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* 2. Address

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* 3. Physician Name

Patient Demographics

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* 4. Patient Gender

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* 5. Patient Age

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* 6. Patient Weight

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* 7. Patient Height

Procedure

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* 8. Operation Date and Time

Date / Time

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* 9. Total Operative Time (00:00)

Product

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* 10. Please rate how well you agree with the following statements.

  Strongly Disagree Disagree Agree Strongly Agree
The available sizes of the implants were appropriate.
The Implant/Instrument interface is adequate to install the system.
The instrument length and thickness did not reduce visibility when installing.
The overall instrument design was appropriate for this technique.
I like the tactile feel of the instruments.
I found the screws easy to work with.
The angle of the screw was appropriate.
The purchase of screw thread was sufficient and strong.
The placement of the cross-link was appropriate and free of problems giving a good range of motion.
I found the cross link locking system useful. (set screw alignment, ease of use)
The set screw/locking cap and final torque on the implant were ideal.
I found the surgical technique guide to be useful.
Overall, I was satisfied with the Gibralt System.

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* 11. Any other suggestions for possible future improvements?

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* 12. Todays Date

Date 

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* 13. Your Name

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