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Thrombosis Ireland Opt-in Survey
Besides email, all other questions below are optional. If you do not wish to be contacted by Thrombosis Ireland, please ignore this survey.
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First name
Date of Birth
Diagnosis (if any, check all that apply)
Risk factor (if any, check all that apply)
Anticoagulation medication
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Email *
Phone (format 087... for Ireland, 00+country code for abroad without spaces)
County of residence in Ireland
Would you like to receive a Patient Information Pack?
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If you answered "Yes" to receiving a Patient Information Pack, please provide your full postal address (including Eircode for precision):
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