INR@Home - INR Self Testing for Coumadin Patients

Please fill out the form below to receive a FREE Raytel INR@Home self-testing information kit. You can also call Raytel customer service, toll free, at 1-877-729-8350. All data collected is kept confidential and is not sold or loaned to any other company or organization. If you choose the mail option, information kit will be delivered regular mail within two weeks.
* Indicates fields that need to be filled out.
Name *
Street Address *
City *
State *
Zip *
Phone Number
E-Mail *
How long have you been on anticoagulant medication?
Is this inquiry related to a mechanical heart valve?			Yes No
Is this inquiry related to chronic atrial fibrillation?			Yes No
Is this inquiry related to venous thromboembolism?			Yes No
If you would like us to provide information on Patient Self Testing to your physician, please provide us with their name and phone number.
Physician Name
Physician Phone Number

Please send me the info kit:			By Mail By Free Download By Both