Continued Use Survey - THE VEST Airway Clearance System
Patient Name* This field is required
Patient Phone Number* This field is required
Serial Number (seven digit number)
Status* Select Pending First Attempt Second Attempt Third Attempt Letter Sent This field is required
Call Date (MM/DD/YYYY)* Not a valid date. Please enter a date in the format "MM/DD/YYYY". This field is required
Employee Name* This field is required
Person Completing Survey Questions* Select Patient Parent Spouse Caregiver Other Family Member Other This field is required
If Other, please document who "other" is.
Has your address changed?* Select Yes No This field is required
Has the Insurance Provider Changed?* Select Yes No This field is required
Is the Prescribing Physician still following the patient?* Select Yes No This field is required
Have you used the device in the last 90 days?* Select Yes No This field is required
If Yes, is there anything else needed?
If No, when was the last time you used the device? (MM/DD/YYYY) Not a valid date. Please enter a date in the format "MM/DD/YYYY".
If unsure of exact date of last usage please share month and week during that month (Example - January, First week).
If no was selected, what is the reason you are not using your device?
*required