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Patient Advisory Board
Application Form
NanoBeat - Patient Advisory Board
Contact Details
Name
(Required)
First
Last
Email
(Required)
Phone
Country of Residence
(Required)
Preferred Language
Level of English Fluency
None
Beginner
Intermediate
Fluent
Patient Organisation Affiliation
Applying as
(Required)
Please select an option
Patient
Caregiver
Advocate
Other
Role
(Required)
Demographics
(Optional, for representation balance)
Age
Please select an option
Prefer Not to Answer
Under 18
18-24
25-34
35-44
45-54
55-64
65 or Above
Gender
Please select an option
Prefer not to answer
Male
Female
Other
Gender – Self-describe
Condition/Lived Experience
(Self-declared, high-level)
Condition experience
Atrial fibrillation (AF)
Conduction disorder (including LBBB)
Other cardiac arrhythmia
Caregiver / family experience
Prefer not to say
Other arrhythmia (high-level description)
Years Living With or Supporting the Condition
Please select an option
N/A
Less than a year
1-3 years
3 - 6 years
6 - 9 years
More than 10 years
Describe your experience/challenges with the current medications you take, treatments/procedures you undergo or devices/technologies you use to manage your condition.
Motivation & Experience
Why do you want to be involved in the NANOBEAT Patient Advisory Board?
(Required)
What skills or experience would you bring?
Availability / Preferred Meeting Times
N/A
Mornings (9:00 AM – 12:00 PM)
Afternoons (12:00 PM - 4:00 PM)
Evenings (4:00 PM - 8:00 PM)
Conflicts of Interest to Declare
GDPR, Privacy & Confidentiality
(Mandatory Acknowledgements)
Privacy Notice
(Required)
I agree to the Privacy Notice.
No Clinical Data Acknowledgment
(Required)
I acknowledge that no clinical data is collected.
Confidentiality Acknowledgment (PAB Discussions)
(Required)
I agree to maintain confidentiality for all PAB discussions.
Consent to be contacted about this EOI
(Required)
I agree to be contacted about this EOI.
(Optional Acknowledgments)
Consent to Share Details with NANOBEAT Partners (Admin Only)
I agree to share my details with NANOBEAT Partners (Admin Only).
Consent to Meeting Recording (If Applicable)
I agree to meeting recordings, if applicable.
