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Westchester Medical Center Transcatheter Heart Program Patient Self-Referral Form 

Please complete this form to be considered for a consultation with the Transcatheter Heart Program at Westchester Medical Center.

* Indicates required information
Today's Date:    (mm/dd/yyyy)
Your First Name: * 
Your Last Name: * 
Your telephone number: * 
Email (optional): 
Alternate Contact (if you would like us to speak with someone else on your behalf) 
How would you like us to contact you? * 

Your physician's name: 
Your physician's telephone number: 
Why are you interested in a consultation?  

If Other, please specify:

Have you spoken with your physician about transcatheter aortic valve replacement (TAVR)? * 

Have you ever been to a Westchester Heart & Vascular practice location?  * 

Authentication * 

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This online form is to be completed by patients only

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