Hypertrophic Cardiomyopathy (HCM) Registry Inquiry Form

Hypertrophic Cardiomyopathy (HCM) Registry Inquiry Form
Name*

First NameLast Name
Email*
example@example.com
Hospital Name*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What Get With The Guidelines® programs does your hospital currently participate in? (select all that apply)

Get With The Guidelines - AFIBGet With The Guidelines - Coronary Artery DiseaseGet With The Guidelines - Heart FailureGet With The Guidelines - ResuscitationGet With The Guidelines - StrokeCardiogenic Shock Registry Powered by Get With The GuidelinesNone
What, if any, hypertrophic cardiomyopathy (HCM) registries does your hospital currently participate in? *

Main Contact(s) - This may be the Site PI, Department Chair, Department Manager, etc.*