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Stroke VICTOR and Caregiver FSR Interest Form
1.
About You
Stroke Victor (I experienced a stroke)
Caregiver (I care for a loved one who experienced a stroke)
Healthcare Professional (I am a professional caregiver)
Other (please specify)
*
2.
How did you hear of the Florida Stroke Registry?
(Required.)
I randomly came across the website
Another stroke victor/caregiver told me about it
My health provider told me about it
I received stroke awareness materials produced by the Florida Stroke Registry
Other (please specify)
*
3.
How would you like to participate in the Florida Stroke Registry
(Required.)
I would like to share my experience
I would like to participate in a local stroke support group
I would like to learn more about the Florida Stroke Registry
Other (please specify)
4.
How can the Florida Stroke Registry better help you
5.
Can the Florida Stroke Registry contact you
Yes
No
*
6.
Your Contact Information
(Required.)
Name
(Last, First)
Suffix
(Dr. Mr. Mrs. Ms.)
Email
Phone Number
Current Progress,
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