Radial Force Group - Application form

Please fill in this application form

Although access to the Radial Force Website is free for anyone, it is very much appreciated if you take a few moments to fill out this form.

By providing these data, an adequate insight in the dissimination of transradial coronary angioplasty is provided, which is useful for proper distribution of information concerning this technique, such as international, national and local meetings and release of new literature and materials.

If you are performing transradial coronary angioplasty, your hospital will be mentioned in the list of centers that applies this technique.

First name
Last name
Title
Address of correspondence	home hospital company
Address
City
State / Province
Zip / Postal code
Country
Telephone
FAX
E-mail

I am	Interventional cardiologist Cardiologist Radiologist Physician Fellow Nurse Technician Industrial Other
Hospital / City

I do perform transradial coronary angioplasty	Yes No
Volume per month; N (%)