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Info Request Form

If you would like to find out more information about the MitraClip™ device and/or the EVEREST II clinical research study, please email us with your questions, concerns and requests. Your message will be directed to the appropriate person at Evalve, Inc. and we will respond directly. All patient information provided in this form is kept confidential and used only for the purposes of determining eligibility to participate in this study. To help us serve you, please complete the following:

General Contact Info:
First Name
Last Name
Address 1
Address 2
City
State
Zip/Postal
Country
Phone
Email


Potential Patients:

Have you or someone you know been diagnosed
with mitral regurgitation (MR)?

No       Yes

Myself       Someone I Know

Comment:


How did you hear about us?

Newspaper
Television
Internet
Radio
Family/Friend
Health Care Practitioner

    Other

Message:


     



You may also want to write, phone or fax us at:

Evalve, Inc.
4045 Campbell Ave.
Menlo Park , CA 94025 , USA
Call (650) 330-8100 or
Fax (650) 330-8114


Caution: Investigational Device. Limited by Federal (or United States) Law to Investigational Use. - Investigational Device. To Be Used by Qualified Investigators Only. Instrument de recherche. Réservé uniquement à l'usage de chercheurs compétents.