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EPR

Exceptional Performance Research | Curasan Physician Study intake form

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Please fill out the information below and press submit. Please contact manager@baysideproductionsllc.com or call 904-323-1462 for any issues.

Download the PDF above or fill out the electronic form below and click submit for Curasan to receive the form.

Study

Date of Surgery
Month
Day
Year

Preoperative Diagnosis and Surgical Treatment

Disease State/Concomitant (Check all that apply)

Select all that apply:

Medication

CERACELL Ortho Foam Product Details

Hydration/Product Preparation

Final Therapy Assessment

Handling during surgery
Very Good
Good
Satisfactory
Adequate
Poor
Tolerability (select one)
Very Good
Good
Satisfactory
Adequate
Poor
Performance
Very Good
Good
Satisfactory
Adequate
Poor

Assessment of Bone formation/resorption (please indicate or tick where necessary)

Assessment Stage
Pre-operative
After approx. 1 month
After approx. 2 months
After approx. 3 months
After approx. 6 months
After approx. 12 months
Date of Assessment
Month
Day
Year
Select all that apply:
CERACELL Ortho Foam visible
Yes
No

Resorption

Resorption Complete
Yes
No
Resorption Partial
Yes
No
Resorption None
Yes
No

New Bone Formation

Complete new bone formation (>95%)
Yes
No
Distinct (75-95%)
Yes
No
Middle (25-75%)
Yes
No
Slight (<25%)
Yes
No

Complications

Infection
Yes
No
Other
No
Other
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