Participate in the Mabu Heart Failure Trial
Thank you for your interest in participating in the Catalia Health Wellness Coach pilot. For our current pilot we are looking for people who have heart failure to try Mabu in their home. Please complete this form so that a member of our team can contact you.
By submitting this form you consent to sending some health-related information to Catalia Health. We strive to protect our patients’ information and will only use this information to determine your eligibility for the program and to better understand where you are on the spectrum of health and disease. The information will not be used for any other purposes.
* Required
Your Name
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Your answer
E-mail address
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Your answer
Phone number
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Your answer
Location (city, state)
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Your answer
Best time to be contacted (optional)
Your answer
Do you have heart failure?
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Yes
No
If yes, what year were you diagnosed?
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Your answer
Are you currently on dialysis for any reason or have End Stage Renal Disease (ESRD)?
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Yes
No
Do you own a scale to weigh yourself with at home?
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Yes
No
Do you currently own and use or are you interested in or curious about virtual assistants? (Examples include Alexa, Google Home, Cortana, and Siri)
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Yes, I own and use at least one virtual agent at home
Yes, I own at least one virtual agent, but don't use it
No, I don't own any virtual assistants but am interested/curious to buy one
No, I don't own any virtual assistants but would try one if it were given to me as a gift
No, I don't own any virtual assistants and have no interest in buying or trying one
Who referred you or how did you find out about this program and Mabu?
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Your answer
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