Enrollment into Ethos is easy and efficient. Just read, complete and submit
the following. We will immediately enroll your institution into Ethos and
send you an invoice for the amount you indicate below.
We look forward to your participation in Ethos.

---

Our organization wishes to participate in the Ethos National Stroke Registry.  We understand that all Ethos services will be provided to our organization at the cost indicated below for the period of one year beginning from the time we first enter data into the registry. We agree to read and comply with the User Agreement and Policies located on the Ethos website at thestrokegroup.com. We also understand that there is no obligation to continue our participation beyond the one-year time period.

Hospital Information

Hospital Name:     Date:
Hospital Location: City:     State/Province:      Country:
Number of active hospital beds:

Hospital Type:
        Yes No Academic/teaching hospital w/full resident support
        Yes No Non-teaching/minimal resident support

Total number of Stroke discharges in previous calendar year:
Population of hospital service/catchment area:

Yes No Unknown	Does the institution have an active designated Stroke Team?
Yes No Unknown	Does the institution have written guidelines (e.g., stroke treatment pathway, standing orders, etc.) or stroke patient management including emergent treatment for stroke patients?
Yes No Unknown	Does the institution have 24/7 capability to perform and interpret either a head CT scan or a brain MRI scan within 45 minutes of the stroke patient being admitted?
Yes No Unknown	Is laboratory hospital support available 24/7 for emergent analysis?
Yes No Unknown	Does the institution have access to a neurosurgeon within two hours, 24/7?
Yes No Unknown	Does the hospital have at least two annual programs to educate the public about stroke prevention, diagnosis, and the availability of acute therapies?
Yes No Unknown	Has hospital administration demonstrated a commitment to the Stroke Program?

---

Hospital Contact for Stroke Report & Registry

Hospital Name:
Contact Person:		Title:		Department:
Street:
City:		State/Province:		Country:
Zipcode:
Telephone:		Fax:		Email:

---

Person Completing this Hospital Profile:

---

Billing Information

Invoice Amount: $1,100

Billing Street Address:
City:		State/Province:		Country:
Zip Code:
PO# (optional):
Your Name:		Title:
Telephone:		Fax:		Email:

---

Special Comments or Instructions:

---