NOVATE MEDICAL - SENTRY IDE STUDY PROCTOR POST VISIT COMMUNICATION
Site # - Enrollment # - Patient Initials
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Site # - 3 Digit
3 Digit Enrollment # & 3 Digit Patients Initials
E-mail
Date of SENTRY IVC filter procedure/Time form generated by Proctor?
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Year
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Have you signed the SPONSOR REPRESENTATIVE SIGN IN Log
YES
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Implanting MD
Has the IMPLANTING MD signed the PROCTOR TRAINING log?
YES
NO
Is the Implanting MD an approved protocol trained physician?
YES
NO
Proctor procedural comments (Double click to edit):
Does the IMPLANTING MD need additional training on the proper use of the device or protocol reinforcement?
YES
NO
Proctor comments regarding screening practices for future cases: (Double Click to edit):
Feedback/observation Details: Provide all information available, as much relevant detail as possible- lot number, procedural details etc
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