Continued Use Survey - SYNCLARA Cough 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*

SYNCLARA Cough System serial number is located on the back of the control unit.

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