Device User Feedback Questionnaire

Welcome to the Device End User Feedback Questionnaire. Using the form below, physicians are able to rate their experience on the use of Epimed products. This input is vital to Epimed’s continued success. The questionnaire takes approximately 3-5 minutes.

"*" indicates required fields

Date of Physician Review*

Customer Number*

Physician Name*

Specialty*

Email*

Phone*

Facility Name

Facility Address*

Select Product Category*

Catheters

Epidural Needles

Nerve Block Needles

Radiofrequency

Trays & Kits

Radiation Safety

Accessories

Select Catheter Product*

Select Epidural Needle Product*

Flexible Introducer Cannula

R.K.™ Epidural Needles

RX Epidural Needles

RX-2™ Coudé®

Tuohy Epidural Needles

Tuohy Single Shot Kit

Select Nerve Block Needle Product*

Blunt Access Cannula

BELLA-D® Needle

Blunt Nerve Block Needle

Chiba Needles

Day Needle

Quincke Needles

STEALTH™ Nerve Block Needle

Select Radiofrequency Product*

Select Trays & Kits Product*

Neo-Kath™ Set

Racz® Catheter MiniTray

RF™ Probe Sterilization Tray

SPIROL® Set

Tuohy Single Shot Kit

Ultrasound Catheter Set CE

Epidural Double Deck Prep Tray

Wiley Spinal®

Select Radiation Safety Product*

IB Radiation Protection Gloves

WRP Radiaxon

XR-SecureTouch

Select Cryoneuroablation Product*

Cryo PainBlocker™ System

Cryo PainBlocker™ Probes

Cryo PainBlocker™ Exhaust Tubing

Cryo PainBlocker™ Mobile Cart

Cryo PainBlocker™ Grounding Pad

Cryo PainBlocker™ Probe Sterilization Tray

Cryo PainBlocker™ Storage Case

Select Accessories Product*

Hidden

Select Charts & Models Product*

Anatomical Charts

GENESIS

Spine Models

THORAXIS

Accura-C™*

251-2010 - Gauge: 20g • Length: 10cm • Tip Size: 10mm

Hidden

Select Variation: Anatomical Charts*

600-VR1620 - Chart Type: Nervous System

600-VR1152 - Chart Type: Spinal Column

600-VR1621 - Chart Type: Spinal Nerves

Select Variation: BELLA-D® Needle*

Select Variation: Blunt Access Cannula*

136-1730 - Gauge: 17g • Length: 3in

135-1825 - Gauge: 18g • Length: 2.5in

135-1837 - Gauge: 18g • Length: 3.7in

135-1857 - Gauge: 18g • Length: 5.7in

Select Variation: Blunt Nerve Block Needles*

Select Variation: Chiba Needles*

115-2235 - Gauge: 22g • Length: 3.5in

115-2260 - Gauge: 22g • Length: 6in

115-2280 - Gauge: 22g • Length: 8in

Select Variation: Cobra RF™*

257-1615 - Gauge: 16g • Length: 15cm • Tip Size: 10mm

257-1610 - Gauge: 16g • Length: 10cm • Tip Size: 10mm

257-1815 - Gauge: 18g • Length: 15cm • Tip Size: 10mm

257-1810 - Gauge: 18g • Length: 10cm • Tip Size: 10mm

257-2010 - Gauge: 20g • Length: 10cm • Tip Size: 10mm

257-2015 - Gauge: 20g • Length: 15cm • Tip Size: 10mm

256-2205 - Gauge: 22g • Length: 5cm • Tip Size: 5mm

Select Variation: Day Needle*

122-2080 - Gauge: 20g • Length: 8in

122-2060 - Gauge: 20g • Length: 6in

Select Variation: Disposable RF™ Probes*

299-5 - Length: 5cm

299-10 - Length: 10cm

299-15 - Length: 15cm

Double Nelson Extension Set*

1911-600

E-KATH™*

154-1912 - Gauge: 19g • Length: 12in

Epidural Double Deck Prep Tray*

191-950

Epidural Flat Filter*

1911-498

FETH-R-KATH™*

157-1924 - Gauge: 19g • Length: 24in

Flexible Introducer Cannula*

135-1735 - Gauge: 17g • Length: 3.5in

G-21 Epidural Catheter™*

158-2114 - Gauge: 21g • Length: 14in

Hidden

Select Variation: GENESIS*

Grounding Pad Cable*

291-C04

Select Variation: IB Radiation Protection Gloves*

500-102-65 - Size: 6.5

500-102-70 - Size: 7

500-102-75 - Size: 7.5

500-102-80 - Size: 8

500-102-85 - Size: 8.5

500-102-90 - Size: 9

Select Variation: Neo-Kath™ Set*

200-2430 - Type: Epidural

201-2430 - Type: Caudal

Select Variation: NEXUS™ Connector*

1911-221 - Gauge: 21g • Type: Epidural

1911-219 - Gauge: 19g • Type: Epidural

Select Variation: Nitinol Hyperflex™ RF™ Probes*

298-5 - Length: 5cm

298-10 - Length: 10cm

298-15 - Length: 15cm

Select Variation: Quincke Needles*

130-2545 - Gauge: 25g • Length: 4.5in

130-2535 - Gauge: 25g • Length: 3.5in

130-2245 - Gauge: 22g • Length: 4.5in

Select Variation: R.K.™ Epidural Needles*

100-1415 - Gauge: 15g • Length: 3.5in

100-1416 - Gauge: 16g • Length: 3.5in

100-1516 - Gauge: 16g • Length: 4.5in

Select Variation: Racz® Catheter MiniTray*

181-2112 - Tray Type: Versa Kath

181-2340 - Tray Type: Brevi-XL

181-2393 - Tray Type: Brevi-Kath

181-2542 - Tray Type: Tun-L-XL/24

Select Variation: Racz® Catheters*

155-2393 - Gauge: 19g • Length: 14in • Model: Brevi-Kath

155-2343 - Gauge: 19g • Length: 14in • Model: Brevi-STF

155-2340 - Gauge: 19g • Length: 14in • Model: Brevi-XL

155-2342 - Gauge: 19g • Length: 14in • Model: Brevi-XL2

155-2350 - Gauge: 19g • Length: 14in • Model: Brevi-XL Pro

155-1520 - Gauge: 19g • Length: 33.25in • Model: Tun-L-Kath

155-2540 - Gauge: 19g • Length: 33.25in • Model: Tun-L-XL

155-2542 - Gauge: 19g • Length: 24in • Model: Tun-L-XL /24

155-2550 - Gauge: 19g • Length: 24in • Model: Tun-L-XL Pro

Select Variation: RF-A™ Sharp Needles*

Select Variation: RF™ Blunt Needles*

RF™ Grounding Pad*

290-GP

RF™ Probe Cable Marker Set*

293-RFPT

RF™ Probe Sterilization Tray*

293-ST

Select Variation: RF™ Sharp Needles*

Select Variation: RX Epidural Needles*

Select Variation: RX-2™ Coudé®*

107-1314 - Gauge: 14g • Length: 4in

107-1614 - Gauge: 14g • Length: 6in

107-1415 - Gauge: 15g • Length: 3.5in

107-1416 - Gauge: 16g • Length: 3.5in

107-1418 - Gauge: 18g • Length: 3.5in

107-1613 - Gauge: 13g • Length: 6in

107-1313 - Gauge: 13g • Length: 4in

Hidden

Select Variation: Spine Models*

600-A72 - Part Type: Cervical Set

600-A74 - Part Type: Full Sacrum Lumbar

600-A76/8 - Part Type: Three Section Lumbar

600-A58/1 - Part Type: Flexible Spinal Column

600-A56/2 - Part Type: Spinal Column with Ribcage

Select Variation: SPIROL® Catheter*

164-1936 - Gauge: 19g • Length: 36in • End Type: Styletted • Closed

164-2024 - Gauge: 20g • Length: 24in • End Type: Styletted • Closed

165-1936 - Gauge: 19g • Length: 36in • End Type: Non-Styletted • Open

166-1936 - Gauge: 19g • Length: 36in • End Type: Non-Styletted • Closed

Select Variation: SPIROL® Set*

202-2036 - Gauge: 20g • Length: 36in • End Type: Styletted • Closed • Needle Type: Epidural

202-1936 - Gauge: 19g • Length: 36in • End Type: Non-Styletted • Closed • Needle Type: Epidural

194-2036 - Gauge: 20g • Length: 36in • End Type: Non-Styletted • Closed • Needle Type: Epidural

168-2014 - Gauge: 20g • Length: 14in • End Type: Styletted • Open • Needle Type: Epidural

193-2036 - Gauge: 20g • Length: 36in • End Type: Styletted • Closed • Needle Type: Caudal

Select Variation: Stainless Steel RF™ Probes*

297-5 - Length: 5cm

297-10 - Length: 10cm

297-15 - Length: 20cm

Select Variation: Standard Extension Set*

1911-512 - Length: 12in

1911-506 - Length: 6in

Select Variation: STEALTH™ Nerve Block Needle*

123-2215 - Gauge: 22g • Length: 1.5in

123-2028 - Gauge: 20g • Length: 2.75in

Select Variation: Stingray® Connector*

1911-321 - Gauge: 21g • Type: Epidural

1911-319 - Gauge: 19g • Type: Epidural

Hidden

Select Variation: THORAXIS*

600-AXIS - Part Type: Housing

600-COREX - Part Type: Replaceable Core

600-CASEX - Part Type: Mobile Case

600-LINEX - Part Type: Fill Line and Syringe

600-DURAX - Part Type: Spinal Tubing

Select Variation: Tuohy Epidural Needles*

125-1635T - Gauge: 16g • Length: 3.5in

125-1735T - Gauge: 17g • Length: 3.5in

125-1835T - Gauge: 18g • Length: 3.5in

125-1860T - Gauge: 18g • Length: 6in

125-2035T - Gauge: 20g • Length: 3.5in

125-2045T - Gauge: 20g • Length: 4.5in

125-2060T - Gauge: 20g • Length: 6in

125-2235T - Gauge: 22g • Length: 3.5in

Select Variation: Tuohy Single Shot Kit*

196-3018 - Gauge: 18g • Length: 3.5in

196-3020 - Gauge: 20g • Length: 3.5in

196-3022 - Gauge: 22g • Length: 3.5in

Ultrasound Catheter Set CE*

170-2124 - Gauge: 21g • Length: 24in • Tip Type: Non-Styletted • Closed

Select Variation: VERSA-KATH®*

156-2112 - Gauge: 21g • Length: 12in

156-2124 - Gauge: 21g • Length: 24in

Select Variation: Wiley Spinal®*

189-2340 - Gauge: 23g • Length: 4in

189-2260 - Gauge: 25g • Length: 6in

Select Variation: WRP Radiaxon*

Select Variation: XR-SecureTouch*

Select Variation: Cryo PainBlocker™ System*

400-PBSYS - System Type: N₂O

401-PBSYS - System Type: CO₂

Select Variation: Cryo PainBlocker™ Probes*

Cryo PainBlocker™ Mobile Cart*

400-PBCRT

Cryo PainBlocker™ Storage Case*

410-PBCS

Cryo PainBlocker™ Probe Sterilization Tray*

411-CPST

Cryo PainBlocker™ Grounding Pad*

420-PBGP

Cryo PainBlocker™ Exhaust Tubing*

412-CCET

Approximately how many years have you been using the selected Epimed product?*

History/Duration of Use

0-1 years

1-3 years

3-5 years

5+ years

If applicable, do you feel the packaging is acceptable to present to the sterile field?*

Packaging

Yes

Not Applicable

On a scale of 1-10, how likely would you be to recommend this product?*

Have you experienced any challenges during use, that in your opinion, were directly attributed to the selected device?*

Yes

What are the advantages of using the selected Epimed device, compared to other similar devices on the market?*

Please list any suggestions you may have for the improvement of the device:*

IHR-527 Rev. 2

Name

This field is for validation purposes and should be left unchanged.

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Device User Feedback Questionnaire

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