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)

Implants used

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* 10. How well did the following areas meet your needs?

  Extremely well Very well Slightly well Not Well at all
A-BOX Device
A-BOX Device Instruments
A-BOX Tray
Marketing/Training Support
Innovasis Support

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* 11. Any other suggestions for possible future improvements?

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* 12. When using the A-BOX System, did the Patient(s) progress as expected?

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* 13. For the A-BOX System that you used briefly, but stopped. Why did you stop using it?

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* 14. For the A-BOX System that you continue to use. How can it better meet your needs?

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* 15. Todays Date

Date 

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* 16. Your Name

T