4.2.2017 Miroslav Cihlo Revision SENSOR RESERVOIR® Registry Hospital name and Department nameHospital AddressReason for revision/explantationDate of RevisionDuration of SENSOR RESERVOIR implantation (days/months)SENSOR RESERVOIR ID numberPressure Measurements before & after SENSOR RESERVOIR ExplantationIn vivo:to be measured 0-24 hours before explantation in lying/recumbent position! Single measurement:Time of dayPressurePressurecm WSm barmm HgTorrhPaplease select the appropriate unitpulsatility visible?YesNoRemarkEx vivo:after explantation in warm saline (34-40°C)Time of dayPressurePressurecm WSm barmm HgTorrhPaplease select the appropriate unitRemarkIf a dysfunction of the explanted SENSOR RESERVOIR is suspected, please send in the product to: Jörg Knebel | Christoph Miethke GmbH & CO. KG | Ulanenweg 2 | 14469 Potsdam | Germany for examination. Use a water-tight container for the shipment. The product must be kept wet (water, saline) at all times. If a new SENSOR RESERVOIR is implanted, please fill in a new “Primary Implantation” form. Thank you!DateNameSignature E-mail This iframe contains the logic required to handle Ajax powered Gravity Forms.