Enrol NowPlease fill out the form below and we will contact you shortly. Thank you! Name * First Name Last Name Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * Please include area code for landline numbers or full mobile number. Your age (in years) * Your sex * Male Female Prefer not to say Prefer to self-describe What type of cardiac event did you have most recently? * Acute Myocardial Infarction (heart attack) Coronary Artery Bypass Graft Surgery (bypass surgery) Percutaneous Coronary Intervention (Stent) Unstable angina Cardiac arrest Pacemaker Heart rhythm disturbance (e.g. atrial fibrillation) Spontaneous Coronary Artery Dissection (SCAD) Other If other, please indicate What was the date of your most recent cardiac event? * Please use DD/MM/YYYY format How did you find out about the Back on Track program? * Social media (e.g., Facebook) Staff at my hospital Staff at my cardiac rehabilitation program My GP Friend / family member Other If other, please specify Are you able to read and understand English language: * Yes No Do you have access to a computer/tablet and the internet? * Yes No Thanks for your interest in our Back on Track Program. Your details have been sent to our Practice Manager who will be in touch with you. If you have any queries please call on 03 9326 8544 or email christina.carrafa@australianhearthealth.org.au
