Amnisure Testimonial Survey



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TESTIMONIAL SUBMISSION FORM

Please submit a testimonial about your experience using AmniSure®.
The testimonials submitted here may be used for educational and/or marketing purposes.

The authors of the testimonials that are selected for such use will be awarded a $100 gift certificate.

Background Data

(All fields are required)

First name		City
Last name		State
Title		Postal Code
Name of Facility		Country
Type of Facility		Email
Facility Address		Phone
Facility Address 2

1. We perform AmniSure® as: POC Test Lab Test

2. What methods did your facility use to diagnose ROM prior to using AmniSure®?

Pooling	Ultrasound	Nitrazine
Ferning	Amnio-dye Infusion	Other (please specify)

3. Has AmniSure® completely replaced these older methods of diagnosing ROM in your facility?
Yes No

4. What professional publications do you read on a regular basis and find the most reliable?

5. What professional websites do you visit on a regular basis and find the most reliable?

Case Study PLEASE FILL OUT ALL APPROPRIATE FIELDS BELOW

Case Date:		Time:
Patient's Gestational Age:	weeks	days

Patient Presentation (example)

Patient Management (example)

Patient Diagnosis (example)

Case Study Conclusion (example)

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Disclosure Agreement:

By clicking "I AGREE" below, I hereby confirm that all the information provided above is accurate and authorize its use by AmniSure® International LLC for education and/or marketing purposes

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Thank you for submitting your testimonial.
Amnisure International LLC
30 JFK Street #4
Cambridge, MA 02138
617-234-4441 phone
617-661-5617 fax
info@amnisure.com

TESTIMONIAL SUBMISSION FORM

Background Data

Disclosure Agreement:

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