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Toll Free: 800 890-9644

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Please complete the form below to help our staff answer your questions more accurately. Certain fields are required to ensure we provide the most appropriate information relative to your individual condition. We maintain the confidentiality of your submission and guarantee this information will not be made available beyond our Center.

The Atrial Fibrillation Center takes the confidentiality of your
information very seriously. For this reason, we use the highest
level of security that technology provides when dealing with
your information. At no time is this information made available
to anyone else.

We thank you for your interest.


Please note: Fields marked with an asterisk require an entry.

 

Full Name*

Email Address *

Phone Number * 

Street Address

City

State / Province

Zip / Postal Coded

Country

 

Clinical Information

 

Date of Birth

Height

Weight

Sex

Male Female

 

Previous / Current Treatment

 

Please select the treatment options you have received:

Medication
Lifestyle changes
Electrical cardioversion
Catheter ablation
Atrial defibrillator

Please state how this condition impacts your life:

How did you find out
about us:

Internet Search Engine
Physician Referral
Friend/Family
Television/News
Other

Type of Health Insurance:

No Health Insurance
HMO
POS
PPO
Comments:

What medicines are you taking?

Do you have a cardiologist?

Yes No

Have you seen an electrophysiologist?

Yes No

If yes, what recommendations were made?

Did your doctor discuss catherization?

Yes No

Did your doctor discuss cardioversion?

Yes No

Are you a normal sinus rhythm?

Yes No

Are you in constant atrial fibrillation?

Yes No

Does your heart go in and out of atrial fibrillation?

Yes No

Why are you seeking surgical treatmet over your current treatment?