Do not include personal identifying information such a patient’s name, birth date, or any personal medical information. Please complete and submit the form below. "*" indicates required fields Name* First Last Email* Enter Email Confirm Email Phone*Date of occurrence* MM slash DD slash YYYY Number of existing patients you cared for with Exersides™ Refraint™ System today:*Select012345Number of new patients you placed in a Refraint™ Device today:Select012345Were there any difficulties with Device Application or Removal?* No Yes Please explain the difficulties:Were there any patient/family/staff issues/concerns/comments?* No Yes Please explain any issues/concerns/comments:Were there any patients who did not qualify for Exersides™?* No Yes Please explain why they didn't qualify:Please send us any additional thoughts and or concerns.CAPTCHANameThis field is for validation purposes and should be left unchanged.
