Product Evaluation Form

Thank you for your product purchase. We hope the product met your needs and expectations. We appreciate you taking the time to complete this form and share your thoughts with us. Receiving feedback about our products is very important to us. Your comments provide us with critical information to improve our products and better meet your needs.

Please complete the following form

Evaluator Information

Name/Title:
Hospital:
City:
State:
Country:
Email:
Phone:
Date of Use:

Description of Injury

Location on Body:
Size and Shape:
Arterial, Venous, Capillary, Unknown:
Source/Cause of Wound:

Application of QuikClot® Hemostat - Product Used:

	QuikClot® Combat Gauze
	QuikClot® Emergency Dressing™ with X-Ray - P/N: 172
	QuikClot® Emergency Dressing™ - P/N: 173

Describe application of QuikClot® Hemostat:
Units used:
Degree to which QuikClot® hemostat controlled bleeding:
Time to control:
Was the patient anticoagulated?
If so, describe the anticoagulant: (asprin, Coumadin®, Plavix®, other)
If known, INR =

Overall Evalutation

Did QuikClot® Hemostat improve outcome?
Were there any adverse events as a result of using QuikClot®?
Would you use QuikClot® Hemostat again?
Additional Information / Comments:

Combat Medical Systems™ | 6441-D Yadkin Road, Fayetteville NC, 28303 | Phone : 910-426-0003 | FAX: 910-426-0009