CONNEQT Health Eligibility Form (V3

Thank you for your interest in the CONNEQT Arterial Health Assessment Service!

To facilitate your order and confirm eligibility, please complete this simple questionnaire. Once your eligibility is confirmed, click “Submit” to be directed to the checkout page.
Reserve?*

YesNo
Are you located in the United States?*

YesNo
The CONNEQT Arterial Health Assessment is not yet available in your country. Please stay in touch, and we’ll let you know as soon as it becomes available in your region.
Where do you reside?*
Why are you interested in assessing your arterial health?*

For personal health monitoringFor professional/clinical use
The CONNEQT Arterial Health Assessment is available for personal use. Please share your contact information, and a member of our team will reach out to discuss professional or clinical use options.
Are you 18 years or older? Please provide your date of birth:*

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Calculated Age
The CONNEQT Arterial Health Assessment is only available to individuals aged 18 and older. Please stay in touch, and we’ll notify you once you become eligible.
Are you currently pregnant?*

YesNo
The CONNEQT Arterial Health Assessment is currently unavailable for those who are pregnant. We encourage you to return once your pregnancy has concluded. Please stay in touch, and we look forward to supporting you on your health journey in the future!
You’re all set to proceed! Just a few last order details.

Once you complete the form below, click ‘Submit’ to be taken to checkout and wrap up your order.
Name*

First NameLast Name
Email*
example@example.com
Your phone number, in case we need to reach you for any updates or questions:*
Please enter a valid phone number.
Your shipping address*
Opt-in:*

I agree to receive updates about the CONNEQT Arterial Health Assessment and other related products and services.
What is your gender?*

FemaleMaleNon-binaryPrefer not to answerOther
What are your conditions and/or use case(s) for seeking an Arterial Health Assessment (select all that apply)*

To monitor my overall cardiovascular healthTo assess my risk of heart disease or strokeTo track the impact of lifestyle changes on my arterial healthTo receive a personalized health report from a cardiologistTo understand how my blood pressure is affecting my arterial healthTo gain insights for better managing an existing heart conditionTo get a clearer picture of my vascular health as I ageAs a preventative measure for long-term heart health management
We handle your information securely, using it only to confirm eligibility, provide a prescription when applicable, and complete your purchase.*

I understand and agree to the Privacy Policy.
For details on how we protect and use your information, please review our Privacy Policy.
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Thank you for your interest in the CONNEQT Arterial Health Assessment Service!

The CONNEQT Arterial Health Assessment is not yet available in your country. Please stay in touch, and we’ll let you know as soon as it becomes available in your region.

The CONNEQT Arterial Health Assessment is available for personal use. Please share your contact information, and a member of our team will reach out to discuss professional or clinical use options.

The CONNEQT Arterial Health Assessment is only available to individuals aged 18 and older. Please stay in touch, and we’ll notify you once you become eligible.

The CONNEQT Arterial Health Assessment is currently unavailable for those who are pregnant. We encourage you to return once your pregnancy has concluded. Please stay in touch, and we look forward to supporting you on your health journey in the future!

You’re all set to proceed! Just a few last order details.