2022 AICD Patient Enrollment Form

Since 2016, Medtronic has donated Implantable Cardiac Devices to SAMA to implant in patients in need in Khartoum, Sudan. These charitable missions have been life-saving to those patients who received them.

For the 2022 mission, this form should be completed by the Mission Team in Sudan to enroll patients. Once completed this form will be reviewed by the Implanting Physicians and SAMA US office for final approval.

For any questions, email admin@sama-sd.org

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Click or drag files to this area to upload. You can upload up to 3 files.
.png, .jpeg, .jpg, .pdf
Click or drag a file to this area to upload.
.pdf
Click or drag a file to this area to upload.
.pdf
Click or drag a file to this area to upload.
.pdf