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Lipogems Equine Scientific Data Collection Form

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This form is for submitting case data to our central database for research and development.

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Lipogems Equine Scientific Data Collection Form

  1. 1. KITE SERIAL NUMBER _ _ _ -_ _ _ _ _ _ -_ _ DATE OF PROCEDURE _ _ -_ _ -_ _ _ _ AMOUNT OF PRE-CANISTER ASPIRATED MATERIAL COLLECTED __________ ml AMOUNT OF LIPOASPIRATE POST- PROCESS __________ ml AMOUNT OF LIPOASPIRATE INJECTED IN EACH ARTICULATION/LIMB/AREA _________ ml ARTICULATION/LIMB/AREA TREATED (please list all details) ________________________________________________________________ ________________________________________________________________ TOTAL LIPOASPIRATE USED __________ ml CASE CLINICAL NOTES (PLEASE CONTINUE ON A SEPARATE SHEET IF NEEDED AND SUPPLY ANY LAB REPORTS OF JOINT FLUID/ XRAYS OR SCANS WHERE APPLICABLE) FOLLOW UP OBSERVATIONS (PLEASE CONTINUE ON A SEPARATE SHEET IF NEEDED) VET & PRACTICE DETAILS: ___________________________________________________________________ ___________________________________ SIGNED:_________________________ Please tick this box if the owner has given NOT given permission for public use of this case. Please tick this box if you are NOT happy for this data to be disclosed to other researchers. Lipogems Equine Data Collection From

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