Post-Procedure Questionnaire

Please complete the form below ON YOUR EXPERIENCE WITH ADVANCED SEAL.

*By submitting this form, you agree to provide your confidential results and assessment to KeriCure Inc. By submitting this form, you agree that the data provided is truthful and accurate, to the best of your ability, and that you give permission to KeriCure Inc. to share this information with the medical practice or physician referenced on the form. KeriCure Inc. will not share any confidential information provided herein with any non-authorized individuals, third party, or any other individual or group. Use of this information for marketing purposes by KeriCure Inc. will not include any confidential information, including patient name or email address.

Name

First Name

Last Name

Medical Practice or Physician who performed the procedure

First Name

Last Name

Procedure Performed

Date of Procedure

YYYY

Date of Follow up (if applicable)

YYYY

o When did you first notice the area healing?

o When do you think the area was fully healed

o What did you look for to judge healing?

o Did you follow the post-procedure treatment regimen as recommended?

o How would you rate the ease of application of the product you used on a Scale of 1 to 5, with 5 being the easiest to use, 1 being very difficult.

o How often did you apply the product after the initial in office treatment?

o For how many days did you apply the product after the initial in office treatment?

o Did this coincide with the # of applications recommended to you?

o Did you have any issues with the application of the product? If yes, please describe.

If Yes to the question above, please describe the issue.

o Did you have any adverse reactions to the product used, such as itching, increase in skin irritation, increase in redness, pain or signs of infection? If so, please describe the reaction, when it occurred, and how you addressed it

o Did you have any concerns with the use of the product?

o If there was redness or irritation as a result of the procedure you had, when did you notice this first lessen?

o Did the product used for post-care provide a soothing or calming effect to the area treated? Did it lessen any post-procedure pain experienced?

o Did the product used for post-care lessen any post-procedure pain experienced?

o Would you recommend this product to other patients?

o If you have had this type of procedure before and used a different post-procedure product for healing, how would you compare your experience, the healing process, and the cosmetic outcome this time to the previous treatment?