In-Hospital Pre-Training Survey- Echo | SonoPath | Fostering the Art of Veterinary Medicine

In-Hospital Training – Echo : Pre-event Information Survey

Email(Required)

First Name(Required)

Last Name(Required)

What state is your license issued in?(Required)

What is your license number?(Required)

*Technicians please put N/A

Professional Code(Required)

(Use the following profession codes for this board: Veterinarian=V; Veterinarian Technician=VT; assistants=N/A) SELECT FROM DROPDOWN!

Veterinary Credentials(Required)

Corporate Affiliation(Required)

Please use NA if you do not have a corporate affiliation.

Company Name(Required)

Address(Required)

City(Required)

State(Required)

Postal Code(Required)

Mobile Phone Number(Required)

Do you have an physical limitations that would limit your scanning abilities, that we should know about?(Required)

Example limitations: Carpal tunnel syndrome, shoulder issues, standing for long periods at a time, etc. We ask this, so that we can be prepared for any special accommodations or alternative suggestions for scanning positions that will best accommodate you.

If yes, please specify(Required)

Please be specific with any physical limitation concerns you may have.

Let us know a little bit about you

Are you familiar with the SDEP® protocol?(Required)

Yes – I have been scanning with the SDEP® Protocol

No – I do not use the SDEP® protocol

Only from watching the training materials

Other

Tell us about your current echocardiogram ultrasound level so we can tailor our teaching and stations to your needs.(Required)

I am a Beginner – limited scanning, do not know what cardiac views are needed, starting from scratch

I am beginner/intermediate – I am familiar with the needed cardiac views and can get most of them most of the time, limited or no experience with measurements and Doppler

I am intermediate – I am fairly confident with my ability to get the needed cardiac views, need refinement on measurements and Doppler

I am intermediate/advanced – I am confident with the needed cardiac views, measurements and Doppler, but need refinement and work on more difficult presentations as well as efficiency

Other

What do you hope to achieve from your In-Hospital Training and going forward? Please be as specific as you can; the more we know, the more we can assist in your goals.(Required)

How many ultrasounds do you currently perform each week?(Required)

1-5

6-10

>10

Do you currently submit cases to a telemedicine company for evaluation?(Required)

We currently use SonoPath for telemedicine

We plan to use SonoPath after training

If yes, please specify the feedback you may have received.(Required)

Does your practice currently have an ultrasound machine?(Required)

Yes

What make and model of ultrasound machine does your practice currently have? How old is it?(Required)

Are you looking to upgrade your current ultrasound system?(Required)

Yes

Would you be interested in(Required)

A pricing consultation for the M11 (distributed in North America exclusively by SonoPath)

Information regarding probes

Asking other questions

Please list your questions here(Required)

How did you find out about SonoPath's In-Hospital Training?(Required)

Previous SonoPath lab attendee

SonoPath Marketing Email

Google Search

Facebook

SonoPath online course

Dr. Lindquist

A friend or colleague told me about it

other

Permission Waivers and Intellectual Property Statement:

Please review the permission waivers below and intellectual property statement.

Social Media, Video & Photograph Permission Waivers:(Required)

YES: I hereby give SonoPath, LLC the absolute right and permission to publish images/pictures of me for promotional purposes in which I may be included in whole or in part. I also understand and grant permission to the rights of my image and sound of my voice as recorded on audio or video tape without payment or any other consideration. I understand that my image may be edited, copied, exhibited, published, or distributed.

NO: I do not grant SonoPath, LLC the right or permission to publish images/pictures/recordings of me for promotional purposes in which I may be included in whole or in part.

Please review the permission waivers above for video, recording, photography and usages that may occur during the In-Hospital Training. There is no time limit on the validity of this release nor is there any geographic limitation on where these materials may be distributed.

Permission Waiver: Digital Signature(Required)

By checking the boxes above and typing my full name in this field, I acknowledge that I have completely read and fully understand the permission waivers and agree to be bound thereby. I hereby release any and all claims against any person or organization utilizing this material for educational purposes.

SonoPath, LLC – Intellectual Property Statement:(Required)

YES: I agree to the intellectual property statement below.

NO: I have questions

INTELLECTUAL PROPERTY STATEMENT: The content of this course, video and procedures are protected under copyright and other intellectual property laws. Video’s supplied to the attendees and/or education information is ONLY for non-commercial private viewing and individual private use only. Any distribution, sharing, copying, teaching, transmission, public performance, alteration, or reverse engineering outside private individual use of purchaser/attendees (unless expressly authorized by SonoPath, LLC) is strictly prohibited and may result in criminal and or civil liability.

If you answered no, please list your questions here:(Required)

Intellectual Property Statement: Digital signature(Required)

By checking the YES box above and typing my full name in this field, I acknowledge that I have completely read and fully understand the intellectual property statement and agree to be bound thereby.

Do you have any additional questions or any other information you would like to provide?