To save time, we encourage you to scroll through this short questionnaire to ensure you have the required information before getting started.  

For background information on WomenHeart's National Hospital Alliance and other WomenHeart programs, please be sure to visit

* 1. Please provide your contact information below.

* 3. Please enter the name and address of the hospital you would like to recommend for WomenHeart's National Hospital Alliance.

WomenHeart has identified the best individuals in the hospital to contact for this opportunity. Please review this list below and use it as a guide to identify the best person(s) WomenHeart should contact at your hospital. Please choose from the following:
  • Nurse Administrator
  • Cardiovascular Service Line (Business) Director
  • Marketing Director
  • Head of the Cardiovascular Division (Physician)
  • Cardiac Rehab Director

* 5. Please provide the name and contact information of the individual you would like WomenHeart to contact for this opportunity. 

* 6. If you would like to provide an additional contact person for your hospital, please include his/her information below:

* 11. In addition to the National Hospital Alliance, there are many ways you can become empowered and raise awareness of heart disease in your community.  Please review the list below and indicate your interest by selecting yes or no for each.

  Yes No
Become a member and receive key heart health information
Receive one-on-one telepone or email support through our SisterMatch program
Knit or crochet for our HeartScarves program
Attend an in-person Support Network
Participate in a Virtual or Online Support Network
Invite a WomenHeart Champion to your next event to share her story and important heart health information
Join us on social media and become a heart health resource for your social networks
Thank you for taking this step towards advancing women's heart health in your community! We will be in touch with you and your hospital with next steps.

* 13. FOR OFFICE USE ONLY: (Do not enter information)