Hospital Teams

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* 1. What is the NAME of your organization?

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* 2. What is your FULL ADDRESS? (street number, street name, city, state, zip code)

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* 3. What is the FULL NAME and CREDENTIALS (i.e. RN, MD) of the administrator you would like to be assigned for your web-based Heart Attack education system? This administrator will be responsible for assigning access to the system to staff at the hospital (nurses/physicians).

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* 4. What is the EMAIL ADDRESS of the administrator you would like to be assigned for your web-based Heart Attack education system?

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* 5. What is the PHONE NUMBER of the administrator you would like to be assigned for your web-based Heart Attack education system?

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