Submitted by ahs-admin on Fri, 03/04/2022 - 11:35 You must have JavaScript enabled to use this form. First Name * Last Name * Date of Birth * MonthJanFebMarAprMayJunJulAugSepOctNovDec Month Day12345678910111213141516171819202122232425262728293031 Day Year19241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Year Phone Number * Address 1 * Address 2 City * State * - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP code * Address * Are you currently being treated for atrial fibrillation? * Yes No Have you had atrial fibrillation for longer than one year? * Yes No Do you have symptoms that can be associated with atrial fibrillation such as palpitations, shortness of breath, dizziness, chest pain, fatigue, decreased activity levels or swelling? OR Do you have difficulty with side effects from the medications you take for atrial fibrillation? * Yes No Have you had open heart surgery? Yes No Based on your responses, you might qualify for the convergent procedure to treat atrial fibrillation. Please continue screening. Are you willing and able to travel to Tyler, TX on four separate occasions for treatment (pre-operative evaluation and tests, stage I surgery, stage II ablation and follow up)? Yes No Thank you for your interest in the convergent procedure to treat atrial fibrillation. Based on your responses, you might be a candidate for the procedure. The next step is to start the referral process and meet with our care team. Are you interested in a telehealth appointment? Yes No Based on your responses, you do not qualify for the convergent procedure at this time. Please follow up with your cardiology for continued management. If you need a cardiologist, UT Health East Texas offers cardiac care across East Texas. Click here to find a provider near you. Leave this field blank Submit
