RESCUE Materials Order Form Survey

1.Please indicated the number of each material you would like to receive. (Required.)

Patient Brochure (Amendment 1 version) - See description above. To be used with the Amendment 1 version of the protocol.

Informed Consent Desktop Flip chart (Amendment 1 version)- See description above. To be used with Amendment 1 version of the protocol.

Eligibility Card (Amendment 1 version) - See description above. To be used with Amendment 1 version of the protocol.

OMT Reminder Card – To be distributed to all clinicians who may have an opportunity to discuss "optimal medical therapy" with study participants as a helpful reminder of OMT specifics.

Participant Card – To be given to each study participant as a reminder about the study and to help him/her inform non-study doctors about their RESCUE participation.

Poster – For display in areas likely to be seen by cardiac patients as well as in general high traffic areas inside or outside the medical facility.

2.Shipping address:(Required.)

Recipient's Name:

Facility Name:

Address:

Address 2:

City/Town:

State:

ZIP:

Country:

Email Address:

Phone Number:

3.If you have any questions or comments about the materials, or would like to suggest ideas for new materials, please respond below.