Initial Screening Questionnaire

Are you 18 years of age or older?*
Have you been diagnosed by a doctor as having advanced Heart Failure?*
Are you in persistent or permanent atrial fibrillation?*
Are you presently on kidney dialysis?*
Have you been told that you might benefit from a heart transplant?*
Are you currently a patient in the hospital because of Heart Failure?*
Have you been told by a doctor that you would benefit from an implantable circulatory assist device, such as a ventricular assist device (VAD), to help support your circulation?*
Are you currently implanted with a ventricular assist device (VAD) other than an intra-aortic balloon pump?*
Are you currently taking one or more medications for Heart Failure?*
Have you been told by a doctor that you have a leaky aortic valve?*
Have you been told by a doctor that you have a severely narrowed aortic valve?*
Are you currently on intravenous (IV) medicines to support your blood pressure or circulation?*
Are you currently a participant in a clinical research trial?*
Are you currently on a list waiting for a heart transplant?*

Authorization

By clicking "I agree" below I represent and warrant that I am at least 18 years of age and have authority to give this authorization for the use or disclosure of my personal information, and that there are no restrictions that would prevent me from authorizing the use or disclosure of this information.

Click here to read the detailed trial authorization.


Authorization*

Basic Details

Note: If you are completing this questionnaire for a loved one, please use the potential participant's name, not your own name.

Note: Please enter only one email address and one phone number in the boxes below. If you have additional contact information you would like to share, please do so via the "Additional Contact Information"  box.

Follow-Up

Follow-Up

Would you like to receive information on future trials that may be relevant to you?*
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