POC Ultrasound – CAS Install / Follow-Up Report

Clinical Applications Specialists (CAS) Contact Information

CAS Name*

First Last

CAS Email Address*

Supporting CAS Name

Facility Name*

Facility Address, City and State*

Street Address City State / Province / Region ZIP / Postal Code

Facility Administrator Contact*

Facility Administrator Phone Number*

Facility Administrator Contact Email Address*

Provider Name*

Provider Email Address*

Install or Follow Up*

System Installation Date by Service*

Start Date*

End Date*

POC Direct or POC Dealer*

Sales Representative Email*

Dealer Sales Rep*

Dealer Sales Rep Email

Service Representative

Ultrasound System*

RS85 Prestige and RS85 V1 Transducers*

CA1-7A Serial Number*

CA1-7S Serial Number*

CA3-10A Serial Number*

CA4-10M Serial Number*

LA2-14A Serial Number*

LA3-22ai Serial Number*

L3-22 Serial Number*

LA4-18A Serial Number*

PA1-5A Serial Number*

Other*

List other transducers and serial numbers

RS80 Transducers*

Other*

List other transducers and serial numbers

V8 Transducers*

CA1-7S Serial Number*

CA3-10A Serial Number*

CA4-10M Serial Number*

LA2-14A Serial Number*

LA3-22ai Serial Number*

L3-22 Serial Number*

LA4-18A Serial Number*

PA1-5A Serial Number*

Other

List other transducers and serial numbers

V7 Transducers*

CA1-7S Serial Number*

CA3-10A Serial Number*

CA4-10A Serial Number*

LA2-14A Serial Number*

LA3-22ai Serial Number*

L3-22 Serial Number*

LA4-18A Serial Number*

PA1-5A Serial Number*

Other*

List other transducers and serial numbers

V5 Transducers*

CA1-7AD Serial Number*

CA2-8AD Serial Number*

CA4-10M Serial Number*

LA3-14AD Serial Number*

LA3-22ai Serial Number*

L3-22 Serial Number*

PA1-5AE Serial Number*

Other*

List other transducers and serial numbers

HS60 Transducers*

Other*

List other transducers and serial numbers

HS50 Transducers*

CA2-9AD
CV1-8AD
LA3-14AD
EVN-4-9
Other

Other

List other transducers and serial numbers

HS40 Transducers*

Other*

List other transducers and serial numbers

HM70 EVO Transducers*

CA1-7AD
CA2-8AD
CA4-10M
LA3-16AD
P3-8
PE2-4
VN4-8
EVN4-9
Other

CA1-7AD Serial Number*

CA2-8AD Serial Number*

CA4-10M Serial Number*

LA3-16AD Serial Number*

P3-8 Serial Number*

Other

List other transducers and serial numbers

HM70A Transducers*

Other*

List other transducers and serial numbers

Advanced Features*

Other Advanced Features

System Details

System Serial Number*

System SW Level*

Providers and Others Trained*

Was a Backup Done?*

Where Was USB Backup Left?*

On system? With Manager, etc

Is this customer using Trophon for HLD?*

Which Trophon Model?*

Wipes Type*

Customer PACS

Training Summary*

Current Customer Equipment*

Concerns/Issues

Any Concerns for Successful Adoption of System OR Concerns for Immediate CAS Follow Up*

VOC's

Do the Systems Being Installed Need Service Attention?*

Service Concerns

Perceived Customer Satisfaction*

Any Files to be Attached to Report

Max. file size: 50 MB.

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POC Ultrasound - CAS Install and Follow Up Report

Clinical Applications Specialists (CAS) Contact Information

System Details

Concerns/Issues