Refer A Patient

Linea Systems appreciates your willingness to refer a qualifying patient.

Physician Name*
First Last
City*
State*
Physician phone number*
Physician e-mail*
Consent?*
We require your consent. You are willing to share your contact information with LINEA System, affiliates, and participating research clinics. You agree to be contacted by a patient coordinator, and if you are eligible and you enroll in the Victorion-Inception cholesterol lowering study, you agree to allow LINEA System to share identifiable information with participating clinics in your local area. See Full Consent Statement

By clicking Submit, you agree to our Full Privacy Policy. You consent to receive phone calls and SMS messages from a patient coordinator to provide updates on your program participation. Message frequency depends on your activity. You may opt-out by texting "STOP". Message and data rates may apply.

By clicking consent you agree that you have obtained the patient consent to be contacted by a Patient Coordinator to further evaluate their eligibility to participate in this trial.
Patient Name*
First Last
Patient phone number
Patient e-mail
At the end of the form click submit referral. If you do not have the patient's phone and email address at this time, simply enter their name at the top of this form and a site liaison will contact your office by the next business day to obtain contact information.
You’re providing the opportunity to your patients to participate in this cholesterol lowering study for those that meet the following eligible criteria. Please check the box next to each qualifier confirming you agree that the patient meets that criteria.
Below Condition is TRUE*
- Must be a male or female of 18 years or older.
Below Condition is TRUE*
- Had a recent Acute Coronary Syndrome (in-patient/out-patient) within the last 5 weeks, defined as: Ischemic symptoms with unstable pattern due to presumed or proven obstructive coronary disease AND at least one of the following:
- Criteria 1: Elevated cardiac biomarkers (cardiac troponin)
  Criteria 2: Resting ECG changes consistent with ischemia or infarction AND additional evidence of obstructive coronary disease.
Below Condition is TRUE*
- Must be willing and able to give informed consent to participate in the study
Below Condition is TRUE*
- Was discharged on statin therapy, or have documented statin therapy intolerance
Below Condition is TRUE*
- Does not have heart failure defined by New York Heart Association (NYHA) class IIIb or IV heart failure or last known left ventricular ejection fraction <25.
Below Condition is TRUE*
- Currently being treated with monoclonal antibodies directed toward PCKS9.
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