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E-mail
*
Mobile phone number
*
Please enter N/A if you don't have a mobile phone
Relative's Name
*
First Name
Last Name
Name
*
Mr.
Mrs.
Miss
Ms.
Dr.
Professor
Reverend
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First Name
Last Name
Date of Birth
*
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Year
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Address
*
Street Address
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City
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Gender
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Male
Female
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Date of birth
*
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31
Day
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Year
Gender
*
MALE
FEMALE
Hospital Number (if known)
Leave blank if not known
Which hospital is your relative seen at? (note we case only accept a self-referral for the hospitals / services listed below)
*
Guy's Hospital
St. Thomas' Hospital
King's College London Hospital
Bexley Community Cardiology Service
Other
What is your relative's diagnosis?
*
Hypertrophic Cardiomyopathy
Arrhythmogenic Ventricular Cardiomyopathy
Dilated Cardiomyopathy
Left ventricular non-compaction
Long QT Syndrome
Brugada Syndrome
Catecholaminergic polymorphic ventricular tachycardia
Idiopathic VT / VF or cardiac arrest of unknown cause
Wolff-Parkinson-White syndrome
Sudden arrhythmic death syndrome
Bicuspid aortic valve
Dilatation / enlargement / rupture of the aorta
Other
Do you or have you ever experienced any of the following symptoms?
*
Chest pain
Breathlessness
Palpitation
Blacking out or fainting
None of the above
Other
Do you or have any of the following conditions?
*
High blood pressure
Atrial fibrillation
Heart failure
Coronary artery disease or heart attack
None of the above
Other
Are there any other details that you think may be relevant?
Please mention any other relevant clinical details or medical history for either you or your relative
Terms and Conditions
*
By submitting this form you consent to your symptoms and medical history being reviewed by a Clinician who may contact you for further details.
How are you related to your relative?
*
I am their son or daughter
I am their biological parent
I am their brother or sister
Other
Who is your relative's heart Consultant?
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