Short QT Syndrome


Patient Form

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This form is provided to allow patients direct contact with Dr. Bjerregaard.

Patient Information:

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Age
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Select any of the following options that apply:

I would like to be considered for a clinical study
I would like my family members screened for SQTS
I need info
on treatment options
I would like to be seen in Dr. Bjerregaard's Clinic

Additional information or questions:


Please provide the following contact information:

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Revised: 04/02/14
 

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