Customer Event Form

  • Reporter Information

  • User Information

  • Device Information

  • Accessories

  • Pad-Pak Information

  • Click here to learn about our FREE Pad-Pak™ Program
  • Patient Information

  • Pre-Existing Medical Conditions (if known)

  • Event Information

  • Location of Resuscitation Attempt

    Please identify the location in which the resuscitation attempt occurred.
  • Please provide additional information about the location (if known).
  • Presenting Heart Rhythm (if known)

  • Please provide additional information about the heart rhythm (if known).
  • Patient Outcome

  • Accepted file types: evo.
  • Forward Hearts