Please read the following information carefully for authorizing the Physician to submit your data to the Afib Quality of Life survey.
By authorizing to submit your clinical and lab data to Afib Quality of Life survey you are informed and understand that:

1. Your identity will not be stored or transmitted by any electric/physical means in compliance with HIPAA rules.
2. Your data can be used for research purposes related to Atrial Fibrillation
3. You are free to withdraw your data from the registry by sending an electronic mail(Email) to customer.support@jafib.com .

I agree to the above conditions and am willing to authorize the physician to deposit the data into Afib Quality of Life survey for research use. By Clicking on the Authorize button I understand that I am electronically signing the authorization form.