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VAD Research Participation Form
Thank you for your interest in participating in our research. Please answer the questions below, and one of our research associates will reach out to you if you qualify for the study.
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* Indicates required question
What is your name?
*
Your answer
Who is implanted with the VAD?
*
Me
My child
Other:
What VAD is being used?
*
Heartware HVAD
Heartmate 2
Heartmate 3
Other:
What is the age of the person implanted with the VAD?
*
Your answer
Approximately when was the VAD implanted?
*
Your answer
At what hospital was the VAD implanted?
*
Your answer
Is the VAD still implanted?
*
Yes
No
What is your email address so that we can reach out to you?
*
Your answer
What is the best phone number to reach you at?
*
Your answer
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