Patient Ambassador Program - Impulse Dynamics

CCM^® therapy is now covered by Medicare

Medicare issued an NCD for CCM^® therapy that covers all FDA-indicated patients over the age of 18 or older, and who have not had a heart transplant.

Click here for more information on NCD

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Home
Patients
Providers
Our Science
- Clinical Studies
  - Aim Higher Study
  - Integra-D
- Publications
Company
Find A Provider
REGION
- North America
- Pacific
  - Australia
  - New Zeland
- Europe
  - Austria
  - Belgium
  - Czech Republic
  - Denmark
  - Finland
  - France
- Europe
  - Germany
  - Hungary
  - Ireland
  - Italy
  - Netherlands
  - Norway
- Europe
  - Poland
  - Portugal
  - Spain
  - Sweden

Patient Ambassador Support Request

"*" indicates required fields

For use by Impulse Dynamics staff only. This form is used to request the engagement of an Impulse Dynamics Patient Ambassador in one of the program types below. When making your request, please do so in keeping the lead times shown below.

Requestor's Information

Name*

First Last

Cell Phone*

Email*

Program Information

Program Type*

If the event is in person event, please allow 15 business days for scheduling. If the event is a virtual event, please allow 5 business days for scheduling. If the event is a peer to peer event, please allow 3 business days for scheduling.

Program Name

Patients Name*

First Last

Patient's Phone*

Patient's Email Address

Program Date

MM slash DD slash YYYY

Program Start Time

Hours

:

Minutes

AM/PM

Program End Time

Hours

:

Minutes

AM/PM

Region

Name of event venue*

Address of event venue*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone of event venue*

Arrival Airport if applicable

Event Venue Notes

Preferred Date (First Choice)*

MM slash DD slash YYYY

Preferred Time (First Choice)*

Hours

:

Minutes

AM/PM

Preferred Date (Second Choice)*

MM slash DD slash YYYY

Preferred Time (Second Choice)*

Hours

:

Minutes

AM/PM

Audience*

Electrophysiologist

Hospitalist

Internal Medicine

Heart Failure Specialist

Fellows

Advanced Practice Providers

Cardiologist

Surgeons

Technician / RN

Impulse Dynamics Employees Only

Other

select 1 or more

Additional Notes*

populate details from selected services above

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