Continued Use Survey - MONARCH Airway Clearance System

Fill out the form below and a member of the Baxter Respiratory Health team will be in contact with you.

Patient Name*

Patient Phone Number*

MONARCH Airway Clearance System serial number can be found via the pendant, or on the product identification label under the backpack cover just over the battery compartment.

Serial Number (seven digit number)

Status*

Call Date (MM/DD/YYYY)*

Employee Name*

Person Completing Survey Questions*

If Other, please document who "other" is.

Has your address changed?*

Has the Insurance Provider Changed?*

Is the Prescribing Physician still following the patient?*

Have you used the device in the last 90 days?*

If Yes, is there anything else needed?

If No, when was the last time you used the device? (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

Respiratory Health

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Hill-Rom® Respiratory Care