Become a Cardiac Rhythm Management (CRM) Patient Ambassador

The CRM Patient Ambassador Program gathers individuals who have received Abbott CRM medical devices and have volunteered to share their personal journey with other patients and healthcare providers.

Please fill out the form below to receive more information about the program and start connecting with others.

* Indicates required field.

First Name*

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

Last Name*

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

Phone*

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

Zip Code*

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

Email Address*

E-mail Address: must be filled in. Field not filled in expected format.

Do you have an AVEIR™ Leadless Pacemaker?*

Yes

No

This Field is a required field.

How do you prefer to be contacted?*

Phone

Email

This Field is a required field.

*

* By checking this box and clicking “Submit”, I agree to join the CRM Ambassador Program (“Program”, and I understand and agree that Abbott and/or its service provider will use the information shared above to contact me by phone or email, including to determine my eligibility to participate in the Program, and send me information about Program event, opportunities, and other Program resources.

This Field is a required field.

*

* By checking this box and clicking “Submit”, I understand and agree that Abbott and/or its service provider will collect and process my Sensitive Data/Consumer Health Data, including information about my health such as condition, treatment and/or health-related management tools, in order to participate in the CRM Patient Ambassador Program. I also understand that I can withdraw my consent at any time by clicking here, however, I will then be unenrolled from the program.

This Field is a required field.

*

* By checking this box and clicking “Submit”, I acknowledge that I have read and understand the Abbott Privacy Policy and Consumer Health Data Privacy Policy.

This Field is a required field.

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