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PRODUCT EVALUATION FORM
(*
required field
)
GENERAL INFORMATION
*
1.
Today's Date (MM/DD/YYYY):
(Required.)
*
2.
Patient's Age:
(Required.)
*
3.
Patient's Gender:
(Required.)
Male
Female
*
4.
Type of Procedure:
(Required.)
*
5.
Product LOT #:
(Required.)
*
6.
Airway Management Device used with the AERIS Airway
TM
:
(Required.)
OPA
NPA
NPA used orally
CLINICAL PERFORMANCE
*
7.
What do you currently use to deliver oxygen during deep I.V. sedation procedures?
(Required.)
Nasal Cannula
Face Mask
Other (please specify)
*
8.
How did the AERIS Airway
TM
ETCO2 waveform compare to what you currently see?
(Required.)
Better
Same
Worse
*
9.
How did the AERIS Airway
TM
deliver oxygen compared to the oxygen delivery device you typically use?
(Required.)
Better
Same
Worse
*
10.
Does your patient monitor offer FIO2 readings?
(Required.)
Yes
No
*
11.
If "Yes" to question 10, when using the AERIS Airway
TM
, was the FIO2:
(Required.)
Higher than what I normally experience
Similar to what I normally experience
Lower than what I normally experience
Do not know
*
12.
Rate your experience using the AERIS Airway
TM
.
(Required.)
Very Satisfied
Satisfied
Dissatisfied
*
13.
Based on your experience, would you be inclined to use the AERIS Airway
TM
for your deep I.V. sedation procedures?
(Required.)
Yes
No
Comments:
PROVIDER INFORMATION
*
14.
Clinician's Name:
(Required.)
*
15.
Name of Hospital/Clinic:
(Required.)
*
16.
Email Address for Follow-Up:
(Required.)
17.
Phone Number for Follow-Up:
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