HFA/HoT Membership Survey

Your feedback is important for us!

If you wish to become more involved in the Heart failure specialists Of Tomorrow (HoT) group, please fill out the boxes below so that we can add you to our mailing lists.

Thank you for your interest and we look forward to working with you soon!

Ewa Jankowska

HoT Coordinator

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1. Your name (Required.)

First name

Last name

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2. Gender (Required.)

Female

Male

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3. Date of birth (Required.)

Date / Time

Date

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4. E-mail address (Required.)

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5. Do you allow the HFA to give your E-mail address to your National Representative? (Required.)

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6. Country (Required.)

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7. Profession (Required.)

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8. Are you in training ? (Required.)

Yes

What specialization ?

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* 1. Your name (Required.)

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* 2. Gender (Required.)

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* 3. Date of birth (Required.)

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* 4. E-mail address (Required.)

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* 5. Do you allow the HFA to give your E-mail address to your National Representative? (Required.)

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* 6. Country (Required.)

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* 7. Profession (Required.)

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* 8. Are you in training ? (Required.)

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* 9. ESC ID number

1. Your name (Required.)

2. Gender (Required.)

3. Date of birth (Required.)

4. E-mail address (Required.)

5. Do you allow the HFA to give your E-mail address to your National Representative? (Required.)

6. Country (Required.)

7. Profession (Required.)

8. Are you in training ? (Required.)

9. ESC ID number