Heart and Stroke Voice Ireland - Request Form • Croi Heart & Stroke Charity

Heart & Stroke Voice Ireland - Join Us Form

Full Name(Required)

Email(Required)

Mobile phone(Required)

Landline

Address

Are you a...

Heart patient/ Heart condition

Stroke survivor

Carer

What is your age range?(Required)

18 – 30

31 – 45

46 – 60

61 – 75

76+

What conditions do you have experience with? (Please check all that apply)

Angina

ASCVD

Atrial fibrillation

Cancer related

Cardiomyopathy

Chronic kidney disease

Congenital or inherited heart disease

Diabetes

Familial hypercholesterolemia (FH)

Heart failure

Heart transplant

Heart valve disease

High cholesterol

Hypertension

Dyslipidemia

Obesity

Rheumatic heart disease

Spontaneous coronary artery dissection (SCAD)

Stroke

Other (if "Other" please specify below)

If you selected "Other" above, please specify:

What is your personal story?

Reason for interest in Heart & Stroke Voice Ireland

Which areas of our work interest you the most (check all that apply):

Patient & carer education

Supporting public awareness campaign

Policy engagement and advocacy

Networking and learning opportunities

Research & Data / Patient and Public Involvement (PPI)/ Research

Storytelling/ Testimonials / Sharing experiences

Access to pre-recorded or curated advocacy, communications, and policy resources, guides, toolkits, and webinars

Advocacy & communication training

How did you hear about Heart & Stroke Voice Ireland?

Heart & Stroke Voice Ireland

Address: Moyola Lane, Newcastle Galway H91 FF68, Ireland

Email: info@heartandstrokevoice.ie

@HSVIreland

Facebook Twitter Youtube Instagram

Heart & Stroke Voice Ireland

Address: Moyola Lane, Newcastle, Galway H91 FF68, Ireland

Email: info@heartandstrokevoice.ie

Facebook Twitter Youtube Instagram

@HSVIreland

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