Daily Feedback Form

Please complete and submit the form below.

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Name*

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Email*

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Phone*

Date of occurrence*

Number of existing patients you cared for with Exersides™ Refraint™ System today:*

Number of new patients you placed in a Refraint™ Device today:

Were there any difficulties with Device Application or Removal?*

Yes

Please explain the difficulties:

Were there any patient/family/staff issues/concerns/comments?*

Yes

Please explain any issues/concerns/comments:

Were there any patients who did not qualify for Exersides™?*

Yes

Please explain why they didn't qualify:

Please send us any additional thoughts and or concerns.

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