2016 Adult Congenital Heart Disease (ACHD) Clinic Survey

General Program Information

7% of survey complete.

Please be prepared to complete the survey in one session. Once you exit or close the survey, you can go back and change existing responses but the survey cannot be left incomplete. Data will only be uploaded into the online Clinic Directory if the survey is completed in full.

Please contact clinicdirectory@achaheart.org if you have any questions or need further assistance. Thank you.

Question Title

1. Name of ACHD Program (this is not the name of the hospital/university that houses the program).

Question Title

2. Year the program was formalized (when half-day sessions were instituted).

Question Title

3. Street address of Clinic (i.e. location where patients go for visits)

Address: *

Address 2:

City: *

State/Province: *

ZIP/Postal Code: *

Question Title

4. Please provide a mailing address as ACHA may periodically send updated programmatic information through the USPS.

Address: *

Address 2:

City: *

State/Province: *

ZIP/Postal Code: *

Question Title

5. ACHD Program Website URL. If none, please indicate N/A.

Question Title

6. Telephone Number for Patient Inquiries

Phone Number:

Question Title

7. Telephone Number for Appointment Requests

Phone Number:

Question Title

8. After Hours Telephone Number

Phone Number:

Question Title

9. Email address for Patient Inquiries

Email Address:

Question Title

10. Do you have a 24/7 ACHD on-call procedure in place?

Yes

Question Title

11. Please provide the name and contact information for the person responsible for ordering and receiving ACHA materials and announcements.

Name

Title

Telephone Number

Question Title

12. Please provide the name and contact information for the person responsible for paying professional membership dues.

Name

Title

Telephone Number

Question Title

13. Please provide the name and contact information for the person responsible for sponsorship opportunities.

Name

Title

Telephone Number