This form can be used by Lipogems accredited vets to submit scientific data to a central database for research and development

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
_________ ml
ARTICULATIONS 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 Canine
Data Collection From