Patients are Partners Interest Form

Welcome!

Vascular Cures is always looking for passionate patients to join our “Patients are Partners” program. Being a Patient Partner starts with sharing your vascular health story to raise awareness about various vascular conditions. Eventually, per your comfort level, it can mean serving as an advisor and/or program participant – your voice plays a valuable role in helping us serve our mission and community.

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* 1. Which of the following categories best describes you?

Patient with vascular disease or history of vascular disease

Family member of patient with vascular disease

Other care provider

Other (please specify)

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* 2. With which type of vascular disease have you or your loved one been diagnosed? Please check all that apply.

Peripheral Artery Disease (PAD)

Stroke

Abdominal Aortic Aneurysm (AAA)

Carotid Artery Disease (CAD)

Arteriovenous Malformation (AVM)

Critical Limb-Threatening Ischemia (CLTI)

Pulmonary Embolism

Deep Vein Thrombosis (DVT)

Chronic Venous Insufficiency (CVI)

N/A

Other (please specify)

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* 3. Which of the following best fits your interest in filling out this form? (Select all that apply)

I am generally interested in learning more about the Patient as Partners program

I am generally interested in learning about Patient Engagement

I am interested in learning how I can use my experience to help others

I am looking for resources for myself/family member

Other (please specify)

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* 4. What is your first name?

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* 5. What is your last name?

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* 6. Please provide your contact information below. We will reach out to you within the next 7-10 days.

Company (if applicable)

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address *

Phone Number

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* 7. Would you like to receive the Patient Community newsletter via email?

Yes

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* 8. What is your preferred method of contact?

Phone Call

Text Message

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* 9. How did you hear about the Patients are Partners Program?

Vascular Cures website

Facebook

Instagram

Twitter

Other