Endocavity Standoff End User
*
1.
Country
(Required.)
2.
Facility
*
3.
Product Used
(Required.)
Endocavity standoff
4.
Item Number(s) Used
*
5.
Procedure(s) Performed
(Required.)
Cryotherapy
HDR Brachytherapy
LDR Brachytherapy
SpaceOAR hydrogel placement
Transperineal biopsy
Other (please specify)
*
6.
Anatomy Targeted
(Required.)
Prostate
Pelvis
Other (please specify)
7.
Rate satisfaction on a scale of 1 to 5 (1 being the lowest level of satisfaction & 5 being the highest level of satisfaction)
1-Low Satisfaction
2
3
4
5-High Satisfaction
Based on product design, rate the ease of use of the standoff in the clinical setting.
1-Low Satisfaction
2
3
4
5-High Satisfaction
Comment
How satisfied are you with the quality of this product?
1-Low Satisfaction
2
3
4
5-High Satisfaction
Comment
How well did the standoff aid in positioning the prostate compared to expectations?
1-Low Satisfaction
2
3
4
5-High Satisfaction
Comment
8.
Based on your clinical expertise, do you believe there is added patient risk associated with the use of this product?
No
Yes (if yes, please explain in Comment box below)
Comment
9.
Please provide your email address in order for CIVCO to respond to any concerns.
