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First Name
Last Name
Phone Number
Email Address
Have you been diagnosed with atrial fibrillation?
Yes
No
Do you have symptoms with your atrial fibrillation that interfere with your life or bother you?
Yes
No
Do your medications prescribed for atrial fibrillation cause side effects that bother you?
Yes
No
Do you have a cardiologist?
Yes
No
Have you been screened for sleep apnea?
Yes
No
Do you have uncontrolled hypertension (HTN) or high blood pressure (HBP)?
Yes
No
Are you interested in learning more about advanced treatments for atrial fibrillation?
Yes
No
If “Yes”, select the location nearest you:
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Dearborn
Farmington Hills
Royal Oak
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