This form is for the exclusive use of practices falling under the KSS and NENC AHSNs.

By receiving and using your AliveCor Kardia device you are participating in a project designed to understand the impact of mobile ECG technology on the detection of Atrial Fibrillation.

By completing this form you are agreeing to the receipt of a AliveCor Kardia device and the accompanying guideline for information governance. Upon setting up your new Kardia Account, you will receive an email invitation from Technomed requesting that you allow access to your Kardia account in order to facilitate data collection in usage.

1. Please enter the email address you have used to set up your Kardia account.

Important: The email address you enter MUST be the same email address associated with your Kardia account.

2. Please re-enter the email address you have used to set up your Kardia account.

3. Please enter the serial number from your AliveCor device.

How do I find the serial number?

4. Please select the Academic Health Science Network (AHSN) that has provided you with the AliveCor Karida device.

5. Please select the CCG area your service was located within on 1st November 2017.

I don't know

6. What is your occupational group

If other, please specify:

7. What type of setting do you work in MOST frequently?

If other, please specify:

Thank you for completing this registration form and taking part in this project. The information from this form is being collected by Technomed on behalf of Kent, Surrey and Sussex (KSS) AHSN and North East and North Cumbria (NENC) AHSN in order to measure the impact of AliveCor Kardia in different settings.

The details that you have provided on this form will be used only for the purposes of monitoring activity of the devices. Your local AHSN will email you with an update on your progress in this project. This project has been extended in KSS and NENC AHSN regions and will now end 31st March 2020, after this time we will not contact you without permission. Technomed Ltd will not contact you or use your details for any other purpose.

As a user of AliveCor Kardia mobile ECG device and app I have read this guidance and I am aware of my responsibility to maintain data security when using these devices. I understand and give my consent to be contacted as part of the evaluation for this project. I understand I can withdraw this consent by contacting my local AHSN.

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T/A ECG On-Demand®

Pulse CheckerAwareness Project

Serial Number Location

Pulse Checker
Awareness Project