Interested in Becoming a WomenHeart Champion? Complete this questionnaire and take one giant step towards helping women in your community! Survey

1.Please provide your contact information below.(Required.)

Name

City/Town

State/Province

Email Address

Phone Number

2.Are you a woman living with heart disease?(Required.)

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

Name of Hospital

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

4.Are you a patient at this hospital?(Required.)

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. (Required.)

Name

Position

Email Address

Phone Number

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

Name

Position

Email Address

Phone Number

7.Do you have a relationship with the person(s) you referred above?(Required.)

8.Would you like to be included in WomenHeart's outreach and presentation to the hospital? If so, you will be contacted via email by a WomenHeart representative.(Required.)

9.If your hospital decides to be a leader in its community by advancing women's heart health through our National Hospital Alliance, WomenHeart will train two women with heart disease at an upcoming Science & Leadership Symposium at Mayo Clinic, to lead a patient support group for women with heart disease. If interested and selected for this extraordinary leadership training, would you be available to attend the symposium October 6th - 9th, 2017?(Required.)

10.If your hospital has not yet decided to join the National Hospital Alliance and you are a woman living with heart disease, would you be interested in becoming a Community Educator by attending the upcoming Science & Leadership Symposium at Mayo Clinic in Rochester, MN, October 6th - 9th, 2017?(Required.)

12.Please tell us how you heard about this opportunity below:(Required.)

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)