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Cardiac Care for Survivors
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Consultation
Study
Teams
Contact
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Enrollment
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Last Name, First Name
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Birthday
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Street and Number
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ZIP and City
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Phone Number
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Email Address
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I would like to make an appointment at the “cardiac aftercare consultation”.
I have already had a cardiac examination in the last 5 years.
Voluntary:
Name of the cardiac specialist
Location (practice address or hospital)
Approximate date of last examination (year)
The study team may request my records from the mentioned cardiac specialist for study purposes.
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