Customer Event Form

  • Reporter Information

  • User Information

  • Device Information

  • Pad-Pak Information

  • Patient Information

  • Pre-Existing Medical Conditions (if known)

  • Event Information

  • Type of Location of Resuscitation Attempt

    Please identify the type of location in which the resuscitation attempt occurred.
  • (For instance, a gym, dentist office, restaurant, park) Please do not provide identifiable information such as place names or addresses.
  • Patient Outcome

  • Details, such as extra information on resuscitation attempt. (For instance, when did ambulance arrive, what actions were taken, survival beyond hospital admission etc.) Please do not provide identifiable information such as city names, hospital names or addresses.
  • Accepted file types: evo.
  • Forward Hearts

  • TERMS: Following are the terms for the Free Pad-Pak and Forward Hearts programs. 1. The event must be an actual sudden cardiac arrest to qualify. 2. The event is verified by the HeartSine Clinical Team, whose decision is final. 3. Exclusions apply. Please contact your sales representative for details. 4. Please do not attach any picture, audio and/or video recording related to the reported event. 5. The person completing this form will ensure compliance with local privacy regulations, and agrees to ensure no identifiable information is contained in this form.

 

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