Applier name *

First Name

Last Name

Patient gender *

Male

Female

Bleed successfully stopped with AutoTQ? *

Yes

No

Terms of Submission *

By submitting this form, you confirm that the information provided may be used by Golden Hour Medical, Inc. for the purposes of analyzing the real-world use and effectiveness of AutoTQ, improving product design, training protocols, and emergency care methods, conducting research and submitting results for scientific publication, and/or sharing anonymized insights for public education and marketing purposes. We may analyze and publish your responses in aggregate, but no personally identifiable information (such as your name, email, or shipping address) will be used in any publication or marketing content. Identifiable information will only be used to contact you regarding your cuff replacement or, if applicable, for follow-up related to your submission. Your personal data will be stored securely and separately from any data used for research or marketing. Your participation is entirely voluntary. By clicking "I accept," you are giving permission for Golden Hour Medical, Inc. to use your submission, in de-identified form, for the purposes described above. If you have any questions about how your data will be used, please contact us at [email protected]. Informed Consent: By submitting this form, you consent to the use of the information you provide for research, product improvement, and educational purposes. Your name, email, and shipping address will not be used in any research publication or marketing materials. Your participation is voluntary, and you may contact us with questions before submitting.

I accept

Replacement recipient: *

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Replacement Shipping Address *

Address 1

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