formlink-patient registration cardiovascular

CARDIOVASCULAR IMPLANT REGISTRATION

(valve, pacemaker, stent, lung and more) for patients

You will follow 3 chapters: 1. identification, 2. implant data, 3. implantation data.
Only fields marked with * are required, but the more you provide, the more we can find out about the implants.

1. IDENTIFICATION

first name*

last name*

country*

ZIP code

city

street, number and more

birthday*

day

month

year

e-mail*

e-mail confirmation*

phone

2. IMPLANT DATA

choose your cardiovascular implant*

implant description, location (you can describe your implant in detail here)

implant company*

implant name

model number

serial number

I got a 2nd implant:

yes

implant description, location (2nd implant)

implant company (2nd implant)

implant name (2nd implant)

model number (2nd implant)

serial number (2nd implant)

3. IMPLANTATION DATA

date of implantation*

day

month

year

clinic of implantation

clinic name street address city postal / ZIP code country

who placed the implant(s) ?

any aspects during the implantation phase

yes

describe the aspects in the implantation phase (max 200 letters)

any aspects during the use phase

yes

describe aspects in the use phase (max 200 letters)

The registrant assures to be the named person to whom the implant was inserted and that all information is correct.

Implantwiki/Implant-Register® assures that the data will not be passed on. They can be evaluated for anonymous, scientific, statistical purposes, where no connection to a person is possible. The data is stored securely.

fee (€ + 7% VAT))*

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