By submitting this form you agree that you understand the above statements and authorize Saving Little Hearts to disclose any and all information regarding treatment received by the minor child listed on this form for his/her congenital heart defect and any and all other health information provided to Saving Little Hearts for the purpose of the Parent Matching Program to any person requesting information through the Saving Little Hearts Parent Matching Program, who has signed up under the Program.
I am providing my information as a
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first time user
parent updating my information
Parent's Name(s)
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Street Address
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Address 2
City
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State
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Zip
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Country
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Phone Number
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Email
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Do you have a website or carepage?
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Yes
No
If yes, website address
Heart Child(ren) Name(s)
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Birth Date(s)
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Death Date (if applicable)
Heart Child(ren)'s CHD
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Other medical problem(s)?
Surgery Dates & Procedures
Cardiologist
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Heart Surgeon(s)
Hospital(s) Used
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Medications
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Sibling(s)/Birth Date(s)
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How did you hear about Saving Little Hearts?
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How can Saving Little Hearts help you?
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Parent Matching
Support Group
Surgery Care Pack
Educational Pack
Educational Materials
Other (list below)
Other
Would you like to be matched with:
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a family in your area with the same CHD as your child
a family in your area with any heart defect
a family not in your area with the same CHD
a family that uses the same pediatric cardiologist
a family that uses the same hospital
If more than one of the above apply, please add additional choices here.
May Saving Little Hearts send your information to Mended Little Hearts (MLH) Parent Matching Program?
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Yes, you can send my information to MLH
No, you cannot send my information to MLH
Submit
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