Akwesasne Heart Valve Mobile Screening Program

Please complete this following form ONCE (per person) to confirm your interest in participating in the clinic.

Please complete all questions until you get to the screen saying 'COMPLETE'

There is a progress bar to give you an idea of how many questions are left.

*All information received will be kept confidential in the Centre for Valvular Heart Disease (CVHD) department and will only be used for the purposes of registration.*