Post-Market Clinical Feedback Form

Thank you for providing feedback on the AMT MiniSPC™ Button - Low Profile Suprapubic Catheter. Please complete one (1) copy of the Evaluation Survey (if you are a caregiver for multiple patients, please complete one (1) survey for each patient in your care). If a question or statement doesn't apply to your experience with the MiniSPC™, you can select "N/A". Please be sure to provide your AMT Device Lot Number and AMT Device Part Number. Please see example images below on where to find this information.

As a thank you for your feedback, you'll have the opportunity to enter a Giveaway at the bottom of this survey.

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* 1. Evaluation Survey Participant:

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* 2. Participant Information:

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Example of where to find your AMT MiniSPC™ Device Lot Number and Part Number (Your device bolster or your product label):

Example of where to find your AMT MiniSPC™ Device Lot Number and Part Number (Your device bolster or your product label):

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* 3. Is the AMT MiniSPC™ button your first suprapubic catheter device?

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* 4. If no, what device was in place prior to receiving you MiniSPC™? (e.g. off-label use of AMT MiniONE® or MiniACE®, other low-profile devices, Cook® Cystostomy Catheter, etc.?)

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* 5. On average, the AMT MiniSPC™ is in place for the following length of time:

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* 6. I exchange, or plan to exchange, the MiniSPC™ at home:

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* 7. Please indicate the degree to which you agree or disagree with each statement below:

  Strongly Disagree Disagree Neutral Agree Strongly Agree N/A
Using the MiniSPC™ is easy and intuitive.
The MiniSPC™ is safe to use for my/my child's urinary drainage needs.
I am able to easily connect and disconnect the MiniSPC™ drainage set.
The MiniSPC™ Drainage Set allows for sufficient flow for urine drainage.
The button’s soft, flexible bolster is easy to clean and less likely to irritate the stoma site.
The design of the button helps to reduce leakage and granulation tissue.
Use of the MiniSPC™ has improved my/my child's quality of life

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* 8. General comments/suggestions:

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* 9. How likely is it that you would recommend the MiniSPC™ Button to a friend or colleague?

Not at all likely
Extremely likely

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* 10. I would like to enter to win a $25 Amazon® eGift Card. Being named a Winner is conditional upon AMT's verification of the entrant's AMT MiniSPC™ Button. Must be 18 years of age or older and legal resident of the 50 United States and District of Columbia to enter.

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* 11. If you selected "Yes" for the above question, please enter your contact information.
I understand that if I did not provide the Device Lot Number in Question 2 (above), I may be contacted for verification of the AMT device for which I am providing feedback. Verification of the device is required to receive a Gift Card.

The Health Insurance Portability and Accountability Act (“HIPAA”) requires an individual to specifically consent and authorize the use of protected health information (“PHI”) before the information is used outside of providing healthcare to the individual. By agreeing below I consent to and authorize Applied Medical Technology (“AMT”), its employees, affiliates, and agents to use the PHI.

I understand that:
  • PHI used or disclosed pursuant to this authorization may be re-disclosed by the recipient and its confidentiality may no longer be protected by federal or state law
  • I have the right to revoke this authorization and future use of the PHI by providing written notice to AMT
  • Once AMT uses the PHI I cannot revoke authorization for that use
  • My treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this form
  • I have the right to refuse to sign this authorization
  • I provide this authorization as a voluntary contribution and hereby release and discharge AMT from all claims to copyright ownership, payment, or other rights that I may have with respect to the PHI

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* 12. I certify that I am 18 years of age or older, I have read the above HIPAA Release of Information, and I fully understand its terms. If completing this survey on behalf of a minor, I represent that I am the parent or legal guardian of the minor and represent that I am authorized to respond on the minor’s behalf. Clicking "Yes" below will serve as an electronic signature; I intend to be bound by my electronic signature.

Thank You for Your Evaluation

Applied Medical Technology, Inc. (AMT)
8006 Katherine Blvd., Brecksville, OH 44141
P: 440-717-4000 / 800-869-7382
F: 440-717-4220
E: CS@AppliedMedical.net

We are committed to keeping your email address confidential. We do not sell, rent, or lease our subscription lists to third parties, and we will not provide your personal information to any third party individual, government agency, or company at any time.

Official Giveaway Rules apply. Participants must complete all required fields of the entry form with information that is valid to be eligible. Prizes will be awarded to the first fifteen (15) eligible entrants, under the condition that the Sponsor is able to verify entrants' use of the AMT MiniSPC™ product for which feedback is given. Giveaway closes on November 30, 2026 at 11:59 PM EST. Full Giveaway rules can be found at https://www.appliedmedical.net/legal/official-rules-and-regulations/
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