Apply for the Cardiac Longevity Programme

Full name

Email address

Phone number

Town or city

What best describes your current situation?
—Please choose an option—Recovering from a cardiac event (heart attack, surgery, etc.)Diagnosed with cardiovascular diseaseCompleted NHS cardiac rehab and want ongoing supportHave cardiac risk factors (BP, cholesterol, inactivity, weight)Other

Briefly tell us about your heart health history

Have you completed NHS cardiac rehabilitation?
—Please choose an option—YesNoCurrently completing itWaiting for itWas not offered it

Are you currently exercising?
—Please choose an option—Yes, regularlyYes, but not consistentlyNo — unsure where to startNo — afraid to exercise

What is your biggest concern right now?

What would you most like to achieve in the next 12 weeks?

Why are you looking for support now?

Are you prepared to commit to a structured 12-week programme?
—Please choose an option—YesPossibly — I would like to discuss itI am not sure yet

Are you comfortable investing in specialist private support if the programme is the right fit?
—Please choose an option—YesIt depends — I would like to learn moreI am not sure yet

Preferred next step
—Please choose an option—I would like to apply for the programmeI would like to book a consultation call firstI am just exploring options at this stage

I consent to my information being used to assess my suitability for the Cardiac Longevity Programme. I understand my data will be handled in accordance with the privacy policy.
I consent to my information being used to assess my suitability for the Cardiac Longevity Programme. I understand my data will be handled in accordance with the privacy policy.