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
I liked the implant/inserter interface favorable and easy to work with.
The instrument length and thickness did not reduce visibility when installing.
The overall instrument design was appropriate for my technique.
I like the tactile feel of the instruments.
I liked the tactile feel of the implants.
The ability to implant was sufficient.
Overall, I was satisfied with the L-BOX Spinal System.
The ability to extract was sufficient (if applicable).
I liked the available sizes of the Implants.
I liked the available lordosis options.
I found the sizer Instruments in the set to be adequate.
I found the shaver Instruments in the set to be adequate.
I found the Box Chisel Instruments in the set to be adequate.
The Implant fit well to the anatomy.
Graft window was easy to fill and work with.
Visualization in X-Ray was clear and easy to interpret.
I liked the tray size and functionality.

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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

T