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Name
*
First
Last
Mobile Number
How long have you had Congestive Heart Failure (CHF)?
*
Newly diagnosed
1-3 years
3-5 years
More than 5 years
Were you recently discharged from the hospital?
*
Yes
No
How long have you been taking ENTRESTO
*
1-3 years
3-5 years
More than 5 years
Are you taking an ACE Inhibitor?
*
Yes
No
How confident are you that you will be successful in following a CHF care plan?
*
Very confident
Confident
Somewhat confident
Not confident at all
I can do it, but would appreciate help and support along the way
What type of support would you want to receive?
*
(Please check all that apply)
Select All
Medication Reminders
Insurance / Reimbursement / Co-pay information
Diet tips and healthy recipes
Education material
Exercise motivation
Other patient's stories and support
Do you want to include a caregiver to support you in your treatment plan?
*
Yes
No
Caregiver Information
Name
*
First
Last
Mobile Number
*
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