Cellular Network Updates

GUIDE-HF Clinical Trial

Request an Upgrade to Your Patient's CardioMEMS Patient Electronics System

If your patient has a CardioMEMS™ Patient Electronics System (PES) currently sending data over a 2G or 3G cellular connection, complete the form below. We will get back to you with details about how to ship their Patient Electronics System to us once we have processed your request and confirmed eligibility.

Please note your patient will be sent a 4G Patient Electronics System before returning their current Patient Electronics System. The patient should continue taking readings as directed with their current Patient Electronics System until their 4G Patient Electronics System is received. Once they have received and taken a reading successfully with their 4G system, they will be asked to ship their 2G/3G system back to us.

The information gathered will be used to send the Patient Electronics System to the patient’s address and, if requested, pair the PES with their sensor serial number.

Patient's First Name*

First Name: must be filled in. Field not filled in expected format.

Patient's Last Name*

Last Name: must be filled in. Field not filled in expected format.

Patient's Date of Birth (DOB)*

Date of Birth (DOB): must be filled in.

Patient's Street Address*

Address: must be filled in. Field not filled in expected format.

Unit / Apt. / Suite

Field not filled in expected format.

City*

City: must be filled in. Field not filled in expected format.

State*

State

Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming

State: must be filled in.

Postal Code*

Postal Code: must be filled in. Field not filled in expected format.

Special Delivery Instructions

Field not filled in expected format.

Patient's Email Address*

Email Address: must be filled in. Field not filled in expected format.

Patient's Phone Number*

Phone Number: must be filled in. Field not filled in expected format.

Patient's Sensor Serial Number*

The number of characters must be equal to 6 Serial Number: must be filled in. The number of characters must be equal to 6

CardioMEMS (CM2000) Sensor Serial Number (SN)
Locate the sensor serial number on the Patient ID Card, or call 1-844-692-6367.

Patient Electronics System Serial Number*

The number of characters must be equal to 10 Serial Number: must be filled in. The number of characters must be equal to 10

CardioMEMS (CM1100) Patient Electronics System Serial Number (SN)
Locate the serial number on the back of the Patient Electronics System.

Preferences and Permissions

Do we have the patient's permission to use their information to pair a 4G device to their sensor in our facility?*

YES

This Field is a required field.

If “No” is selected above, then Abbott will not pair the Patient Electronics System to the patient’s implanted sensor. The patient will be required to pair their Patient Electronics System to their implanted sensor at home or with their physician at their clinic.

I, the treating physician, or research coordinator, spoke with the patient to gain consent and attest the information provided is correct.*

I Agree

This Field is a required field.

Site Name*

Site Name: must be filled in. Field not filled in expected format.

GUIDE-HF Subject ID*

GUIDE-HF Subject ID : must be filled in. Field not filled in expected format.

Site Contact – Name*

Site Contact – Name: must be filled in. Field not filled in expected format.

Site Contact – Phone Number*

Site Contact – Phone Number: must be filled in. Field not filled in expected format.

*I agree to Abbott's Privacy Policy

I Agree

This Field is a required field.

*I have read and agree with the Terms and Conditions

I Agree

This Field is a required field.

By completing and submitting this form, you agree to being contacted by Abbott by mail, telephone or by non-password protected electronic communications, such as emails. Abbott may exchange information with you regarding our products or services or inquire about your experience. Your information will not be used for purposes other than what’s stated here.

Abbott respects the confidentiality of your personal information. We will not share your personal information except as described above. If at any time you wish to revoke all or part of this permission, you can email us at privacy@abbott.com or send a request in writing to:

Abbott
Attention: Privacy Officer
036X, AP06A-2
100 Abbott Park Rd
Abbott Park, IL 60064

Privacy Policy
Abbott respects the confidentiality of personal information. We assure you we will not share your personal information, except as otherwise noted in our privacy policy.

MAT-2110648 v1.0

CARDIOVASCULAR

Cellular Network Updates

GUIDE-HF Clinical Trial

Request an Upgrade to Your Patient's CardioMEMS Patient Electronics System

Preferences and Permissions

POLICIES & ADVISORIES

HEALTHCARE PROFESSIONALS

PATIENTS & CAREGIVERS

CARDIOVASCULAR

Cellular Network Updates

GUIDE-HF Clinical Trial

Request an Upgrade to Your Patient's CardioMEMS Patient Electronics System

Preferences and Permissions

POLICIES & ADVISORIES

HEALTHCARE PROFESSIONALS

PATIENTS & CAREGIVERS

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