Outcomes Monitoring: 30 Day Survey - The Synclara™ Cough System

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

Patient Name*

Patient Phone Number*

Patient Date of Birth (MM/DD/YYYY)*

Serial Number

Are you able to complete your therapy as prescribed? If no, why not? *

Other (please explain)

How would you evaluate the overall therapy in meeting your needs?*

How would you evaluate the comfort of the therapy/device (relative to your expectations)?*

What is the likelihood you would recommend this therapy to others?*

Reason for Rating

We’d love to hear from you on your overall experience with the therapy. If willing, please share how this therapy has impacted you positively/negatively in your day to day life.

Do you need replacement supplies?* Yes
No

If yes, what supplies do you need?

Clinical Follow-Up Please have a clinician contact me within the next 3 business days

*required

Respiratory Health

Advancing respiratory health through innovative therapies

Hill-Rom® Respiratory Care