Share Your Total Artificial Heart Story

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1. Your Name(*)
   Please fill out Your Name
2. Email Address(*)
   Please provide us with a valid email address
3. Street Address
   Please fill out your street address.
4. City
   Please provide us with your city
5. State/Province
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6. Zip Code
   Please provide your zip code
7. Phone Number(*)
   Please provide your phone number
8. Country(*)
   Please Select...United States of AmericaAfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua & BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaireBosnia & HerzegovinaBotswanaBrazilBritish Indian Ocean TerBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCayman IslandsCentral African RepublicChadChannel IslandsChileChinaChristmas IslandCocos IslandColombiaComorosCongoCook IslandsCosta RicaCote D'IvoireCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerGabonGambiaGeorgiaGermanyGhanaGibraltarGreat BritainGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuyanaHaitiHawaiiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalaysiaMalawiMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMidway IslandsMoldovaMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNambiaNauruNepalNetherland AntillesNetherlandsNevisNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorwayOmanPakistanPalau IslandPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSt BarthelemySt EustatiusSt HelenaSt Kitts-NevisSt LuciaSt MaartenSt Pierre & MiquelonSt Vincent & GrenadinesSaipanSamoaSamoa AmericanSan MarinoSao Tome & PrincipeSaudi Arabia,SenegalSeychellesSerbia & MontenegroSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSurinameSwazilandSwedenSwitzerlandSyriaTahitiTaiwanTajikistanTanzaniaThailandTogoTokelauTongaTrinidad & TobagoTunisiaTurkeyTurkmenistanTurks & Caicos IsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUzbekistanVanuatuVatican City StateVenezuelaVietnamVirgin Islands (Brit)Virgin Islands (USA)Wake IslandWallis & Futana IsYemenZaireZambiaZimbabwePlease provide the Country you live in
9. Age (at Implant)
   Please provide your Age at the Total Artificial Heart Implant
10. Occupation
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11. Hospital(*)
    Please provide the Hospital that implanted your Total Artificial Heart
12. What Month & Year did you receive the Total Artificial Heart? (if you don’t know for sure, please provide your best guess)
    Please provide what Month & Year you received the Total Artificial Heart? (if you don’t know for sure, please provide your best guess)
13. If applicable, what Month & Year did you receive your heart transplant? (please provide your best guess)
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14. When were you first diagnosed with heart problems?
    Please provide when you were first diagnosed with heart problems
15. Describe how were you first diagnosed with heart problems:
    Please describe how were you first diagnosed with heart problems
16. Describe the symptoms and events leading up to implant of the Total Artificial Heart:
    Please describe the symptoms and events leading up to implant of the Total Artificial Heart
17. Describe your experience while on the Total Artificial Heart:
    Please describe your experience while on the Total Artificial Heart
18. Describe your life post-transplant:
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19. What would you tell others about the Total Artificial Heart?
    Please tell us what you would tell others about the Total Artificial Heart
20. Photos make a big difference when telling your story. If you would like to share your personal photos with SynCardia, please attach them here. Great examples include photos of you and your family, significant other, friends, etc. doing everyday activities while on the Total Artificial Heart, such as exercising, celebrating birthdays or anniversaries, going for walks, etc. Other great examples include you doing activities you enjoy post-transplant.
21. Upload Image
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22. Please enter the text in the image
    
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23. Submit