Medical Device Usage Report

If you have used your Kesite in a choking emergency, please fill out the form below to receive a free replacement of your Kesite unit.

Contact Information

Full Name *

Email *

Phone Number

Device Information

Device Model *

Purchase Date

Incident Information

Incident Date *

Incident Time

Patient Age

Patient Gender

Choking Object

Location

Treatment Information

First Aid Attempted Before Device Use

Was the Device Effective? *

Number of Attempts

Outcome *

Additional Details

Additional Comments or Details

Consent & Authorization

I consent to have this case reviewed by medical professionals for quality improvement purposes.I consent to have this case used in anonymized case studies or research.I consent to be contacted for follow-up questions about this incident.