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Patient Information
Please do NOT provide the patient’s name or contact details with this feedback form
How many wounds were treated by the product?
Date and approximate time of incident / injury
Patient age
Gender
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Female
Male
Other
What was the cause of the injury?
What were the patient signs and symptoms upon arrival?
Were there any additional patient conditions?
Device Use
Which CELOX Gauze device was used?
...
10ft/3m roll
10ft/3m Z Fold
5ft/1.5m Z Fold
First Aid 8x8
First Aid 4x4
EMS 8x8
EMS 4x4
Other
Which CELOX Granules device was used?
...
15g
2g
Other
If no, please explain the method you used to apply the product and stop the bleed
If no, why?
If yes, how many chest wounds did the patient have?
If no, what went wrong?
If no, what type of wound was it used for?
How many FOXSEALS were used?
How many FOXSEAL Vented were used?
If yes, how did you treat the patient?
If no, describe why?
What did you use to cover and apply compression to the wound?
If yes, please provide details
If yes, how many minutes compression was used?
If yes, how many packs of Applicator were used?
If no, how did you stop the bleed?
If yes, what were the conditions causing the re-bleed?
Reason for death, if known
Please provide any other comments
If possible, please provide contact details of the medical facility, the casualty was transferred to
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