Product Evaluation Form

Thank you for providing feedback on the AMT MiniONE® Balloon Button or MINI™ Classic Low Profile Button G-Tube. Please complete one (1) copy of the Evaluation Survey (if you are a caregiver for multiple patients, please complete one (1) survey for each participant in your care). Answer each question to the best of your ability. If a question or statement doesn't apply to your experience with your product, you can select "N/A".

As a thank you for your feedback, you’ll have the opportunity to enter a Giveaway at the bottom of this survey.

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* 1. Evaluation Survey Participant:

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* 2. Participant Information:

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* 3. I currently use the following AMT product (select one):

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* 4. On average, the selected device is in place for the following length of time:

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* 5. I exchange (or plan to exchange) the selected device at home:

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* 6. What type of nutrition do you use (e.g., formula (powder or pre-mixed), real food blend (homemade or store-bought), or a combination of products)?

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* 7. I use an AMT feed/extension set (purple adapter with Glow Green™ connector)?

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* 8. I use a MIC-KEY® feed/extension set (light blue adapter with white connector)?

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* 9. I use the following type of feed/extension set:

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* 10. I use the following method to deliver nutrition (select all that apply):

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* 11. Please indicate your satisfaction with the following product features:

  Very Dissatisfied Dissatisfied OK Satisfied Very Satisfied N/A
Size of External Bolster
French Sizes Offered
(12F, 14F, 16F, 18F, 20F, 24F)
Stoma Lengths Offered
(0.8 cm to 10 cm)

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* 12. Please indicate your satisfaction with device removal/exchange:

  Very Dissatisfied Dissatisfied OK Satisfied Very Satisfied N/A
Ease of Removing the Selected Device
Ease of Exchanging the Selected Device

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* 13. Please indicate your satisfaction with the following safety and performance features:

  Very Dissatisfied Dissatisfied OK Satisfied Very Satisfied N/A
Device Stability within the Stoma
Ease of Feeding
Ease of Medication Delivery
Ease of Decompression
Device Longevity

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* 14. Please indicate the degree to which you agree or disagree with each statement below:

  Strongly Disagree Disagree Neutral Agree Strongly Agree N/A
The DFU for the selected device provides adequate instruction.
Using the selected device is easy and intuitive.
I am able to easily connect and disconnect the feed/extension set.
I am able to successfully decompress/vent the selected device.
The selected device is safe to use for my/my child’s enteral nutrition needs.
I have not experienced negative side effects while using the selected device.

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* 15. Discuss any issues/problems you encountered while using the selected device (delivering nutrition or medicine; decompressing/venting; etc.):

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* 16. Discuss any product improvements or additional product sizes you think AMT should offer:

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* 17. How likely is it that you would recommend the selected device to a friend or colleague?

Not at all likely
Extremely likely

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* 18. General comments/suggestions:

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* 19. I would like to enter for a chance to win a $25 Amazon® eGift Card. Being named a Winner is conditional upon AMT’s verification of the entrant’s MiniONE® Balloon Button or MINI™ Classic Low Profile Button G-Tube. Must be 18 years of age or older and a legal resident of the 50 United States and District of Columbia to enter.

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* 20. If you selected “Yes” for Question 19, please provide your contact information. I understand that if I did not provide the Device Lot Number in Question 2, I may be contacted for verification of the AMT device for which I am providing feedback.

The Health Insurance Portability and Accountability Act (“HIPAA”) requires an individual to specifically consent and authorize the use of protected health information (“PHI”) before the information is used outside of providing healthcare to the individual. By agreeing below I consent to and authorize Applied Medical Technology (“AMT”), its employees, affiliates, and agents to use the PHI.

I understand that:

  • PHI used or disclosed pursuant to this authorization may be re-disclosed by the recipient and its confidentiality may no longer be protected by federal or state law
  • I have the right to revoke this authorization and future use of the PHI by providing written notice to AMT
  • Once AMT uses the PHI I cannot revoke authorization for that use
  • My treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this form
  • I have the right to refuse to sign this authorization
  • I provide this authorization as a voluntary contribution and hereby release and discharge AMT from all claims to copyright ownership, payment, or other rights that I may have with respect to the PHI

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* 21. I certify that I am 18 years of age or older, I have read the above HIPAA Release of Information, and I fully understand its terms. If completing this survey on behalf of a minor, I represent that I am the parent or legal guardian of the minor and represent that I am authorized to respond on the minor’s behalf.

Thank You for Your Evaluation

Applied Medical Technology, Inc. (AMT)
8006 Katherine Blvd., Brecksville, OH 44141
P: 440-717-4000 / 800-869-7382
F: 440-717-4220
E: CS@AppliedMedical.net
We are committed to keeping your email address confidential. We do not sell, rent, or lease our subscription lists to third parties, and we will not provide your personal information to any third party individual, government agency, or company at any time.

Official Giveaway Rules apply. Participants must complete all required fields of the entry form with information that is valid to be eligible. Prizes will be awarded to the first fifteen (15) eligible entrants, under the condition that the Sponsor is able to verify the entrants’ use of the MiniONE® or Mini™ Classic Balloon Button for which feedback is given. Giveaway closes on November 30, 2024 at 11:59 PM EST. Full Giveaway rules can be found at https://www.appliedmedical.net/legal/rules-regulations/

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MIC-KEY® is a registered trademark of Avent, Inc.
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