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help other patients by sharing your story

If you received Aquapheresis Therapy using Aquadex FlexFlow, we want to hear from you. Complete the form below to get started. We may contact you to collect more information. Please review our legal terms and privacy policy.

The Patient Stories are to be about real patients and their actual experiences with aquapheresis treatment. They can be written by patients themselves and we welcome friends and family of patients to let us know what they thought about the treatment and the effect on their loved ones.

* Required Field

Name: *  
Patient?: *
If no, what is your relationship to patient?
Address: *  
Phone #: *  
Email: *  
Fluid overload due to...
Gender:
Age:  
Doctor who prescribed the therapy:
Hospital or clinic:
Patient Story:
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Legal Terms:

By submitting your story to CHF Solutions, Inc., you agree to the following:

CHF Solutions is planning on using the information you submitted for worldwide distribution. The information you submit may be published and distributed in any number of forms, including, but not limited to, print media, electronic media, audio/visual media, and/or via the Internet. If you would not like your name to be in the distribution, indicate so in your testimonial.

You agree and acknowledge that CHF Solutions, will not be required to seek any further approval from you in connection with the publication of this information for the stated purposes. Should CHF Solutions desire to use the information for any other purpose, CHF Solutions, agrees that it shall submit advance copies for your approval prior to publication. Consent to such publication and distribution shall not be unreasonably withheld by you.

Please keep a copy of this for your records and again, thank you for sharing your experiences. Please read our privacy policy as well.

 

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