Navilloon-e feedback form Surgeon Name:(*) Please enter your name Date(*) ... Please select the date Hospital(*) Please enter your hospital/surgery name. Theatre or Out-Patient Procedure(*) TheatreOut-Patient Please select a procedure Balloon Diameter details details: Device Used(*) MG-BC-0301 E (3mm x 20mm)MG-BC-0601 E (6mm x 20mm) Please enter device details Existing equipment details: Current equipment used(*) Please enter equipment details What challenges do you have with existing equipment? (*) Please enter challenge details What do you like about existing devices?(*) Please enter what you like about existing devices Thinking about your recent experience, how would you rate the Navilloon-e product for the following? 1) Feel / Ergonomics(*) 1) Very Poor2) Poor3) Average4) Good5) Very Good Please enter details about your recent experience 2) Capacity to bend the Intro Guide(*) 1) Very Poor2) Poor3) Average4) Good5) Very Good Please enter details about your recent experience 3) Capacity to rotate the Intro Guide(*) 1) Very Poor2) Poor3) Average4) Good5) Very Good Please enter details about your recent experience 4) Ease of insertion using the Balloon Controller(*) 1) Very Poor2) Poor3) Average4) Good5) Very Good Please enter details about your recent experience 5) Ease of Maintaining Balloon Inflation(*) 1) Very Poor2) Poor3) Average4) Good5) Very Good Please enter details about your recent experience 6) Speed of use(*) 1) Very Poor2) Poor3) Average4) Good5) Very Good Please enter details about your recent experience Comments about overall performance(*) Please comment on the overall performance Thank you for sharing feedback about Mega Medical Navilloon-e devices Would you recommend Navilloon-e to a colleague?(*) YesNo Please enter a value Would you be happy to use Navilloon-e for future cases? (*) YesNo Please enter a value Would you be interested in local education events for either yourself or trainees?(*) YesNo Please enter a value Name of Severn Healthcare representative: Andrew PlumptonChris EatonOliver DaviesJames BradleyAndrew DobsonBrett HallPaul WasmuthNitesh Pankhania Please select a name Submit form
