Register or sign-in as a physician or other professional

A unique Identification number will be created for the case you are submitting to the registry. Submit each case for a patient only once being careful not to disclose the patients name or to include information that would disclose the patients identity or enable someone to identify the person..

Obtain Submission Packet.
After you register, receive a case number and submit case information, we will email you a submission packet containing the forms to be completed.

Put the case number on the Forms and complete the forms.

Prepare your submission package.
All items should be labeled with the unique Case Number that was assigned when you registered and created a case. Remove the patients name or any information that could lead to the person's idenfication.

You should return to us:

• Completed Registration Submission Form
• 12 lead ECG (hard copy and electronic format if possible). Please include ECG taken before the patient was given suspect drug, while taking the drug and after stopping the drug if at all possible.
• Rhythm strips for arrhythmia documentation if available

Mail the above materials to

AZCERT, Inc., 1822 E. Innovation Park Dr., Oro Valley, AZ 85755, USA