Cardiogenic Shock Inquiry Form

Hospital Name*

Address

City

State

What GWTG programs does your hospital currently participate in?

(select all that apply)

Select

What, if any, cardiogenic shock registries does your hospital currently participate in?*

Main Contact(s)*

This may be the Site PI, Dept. Chair, Dept. Manger, etc. If there are multiple contacts, please provide a list of all, separated by commas.

Email address(es)*

If multiple contacts are listed above, please provide an email for each person, separated by commas.

Inquiry Type*

Select

What EHR or EMR systems are used in your hospital?*

Comment/Question*

Send me a copy of my responses