Candidate Screening

Has your doctor diagnosed you with Heart Failure? (Required)

Yes

No

Are you still experiencing heart failure symptoms despite being on medications prescribed by your doctor for heart failure?(Required)

Yes

No

My Heart Failure symptoms limit my ability to do basic activities of daily living (examples: climbing stairs, getting dressed, checking the mail, walking the dog, etc.)(Required)

True

False

Do you know your heart's pumping ability (ejection fraction)?(Required)

Yes, > 60%

Yes, 45 - 60%

Yes, 25 – 45%

Yes, < 25%

I don’t know my EF

Have you ever been diagnosed with any of the following conditions? (Select all that apply)(Required)

Cardiac Arrest

Multiple Sclerosis

Chronic Obstructive Pulmonary Disease (COPD)

High Blood Pressure

Diabetes

No - I have not been diagnosed with any of the above conditions

Which of the following best describes your insurance coverage? (Required)

Medicare

Medicare Advantage

Medicaid

Private Insurance

Veteran's Administration (VA)

Uninsured

One last step...Please tell us about yourself to see if you may be a candidate for CCM therapy. This information will only be used by Impulse Dynamics and will not be sold to a third party.

My name is(Required)

First Last

Zip Code(Required)

Click here if you are submitting on behalf of a loved one:

Yes, I am submitting on behalf of a loved one

By checking this box, I agree to receive SMS communications from Impulse Dynamics for the purposes of receiving additional information about CCM Therapy. Message and data rates may apply. See our terms & conditions and privacy policy here. Reply STOP to opt-out at any time.”(Required)

Yes, I agree to SMS communications

Email(Required)

Phone(Required)

Choose your preferred next step if CCM Therapy is right for you: (Select all that apply)(Required)

Meet with an Experienced CCM Provider

Receive additional information about CCM via email

Attend a Live Webinar led by a CCM Trained Doctor

Talk one on one with a CCM Implanted Patient

By clicking 'See My Results' you agree to receive automated text messages. This agreement isn’t a condition of any purchase. Reply STOP to end. Any personal data you provide will be processed by Impulse Dynamics in order to respond to your query and to comply with our legal obligations. If you are sharing health data with us then by, submitting this form, you are consenting to our using your health data for those purposes. Your personal data is shared may be shared with safety personnel and regulators. To access, rectify, request deletion of your personal data, or to withdraw consent, please contact us at privacy@impulsedynamics.com. For more information on how we process your personal data, please check our Privacy Policy.

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UUID

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Entry Date

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Quiz Score Total

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Quiz Data

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Patient ID

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Owner

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Find a Doctor URL

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Referral

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Phone (Duplicate)

Are you a candidate for CCM® Therapy?

Are you a candidate for CCM^® Therapy?