Eclipse Diagnostics Stroke Survivor Form
The purpose of this form is to share your stroke story and its recovery in order for us to better understand your post-survivor needs, so that we can develop a more convenient and useful preventive solution that will fit you best. Your answers will be kept confidential unless you allow its publication.
Email address *
Full Name *
Your answer
Date of birth *
MM
/
DD
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YYYY
When did you get a stroke? *
MM
/
DD
/
YYYY
What type of stroke did you have? *
Did you notice any health warning signs hours or days before you had a stroke?
Your answer
Here you can share your story about your stroke 'experience' and recovery. How was it?
Your answer
Would you be willing to take a blood prick regularly at HOME in order to monitor the risk of a new stroke? *
If Yes, how often would you be willing to do it? *
Do you allow us to publish parts of your story online: your full name and email will not be displayed? *
Do you have any questions for us?
Your answer
Would you like to receive our Newsletter? *
Privacy Policy, Terms and Conditions and HIPAA compliance
Please refer to the Privacy Policy and Terms and Conditions on our website (www.eclipsedx.com).

We are not "HIPAA compliant." Users are solely responsible for any applicable compliance with federal or state laws governing the privacy and security of personal data, including medical or other sensitive data. Users acknowledge that the Services may not be appropriate for the storage or control of access to sensitive data, such as information about children or medical or health information.

Eclipse Diagnostics Inc. does not control or monitor the information or data you store on, or transmit through, our Services. We specifically disclaim any representation or warranty that the Services, as offered, comply with the federal Health Insurance Portability and Accountability Act ("HIPAA"). Customers requiring secure storage of "protected health information" under HIPAA are expressly prohibited from using this Service for such purposes. Storing and permitting access to "protected health information," as defined under HIPAA is a material violation of this User Agreement, and grounds for immediate account termination. We do not sign "Business Associate Agreements" and you agree that Eclipse Diagnostics is not a Business Associate or subcontractor or agent of yours pursuant to HIPAA. If you have questions about the security of your data, please contact our team.

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