A support and information network for those with congenital heart defects
Email address:
May we release your information to other members of California Heart Connection?
Do you speak any languages other than English? If so, please list:
Becoming a member of Californa Heart Connection is easy and free - just fill in the information below and hit the submit button. Members receive updates on future events and have access to our online support group. We value your privacy and will keep all information confidential, unless you give us express written or electronic permission to share it with other members of California Heart Connection.
Please note: California Heart Connection serves those who reside in California or who seek healthcare services in California. Keeping our local focus helps us to keep information relevant to our members and keep costs down. If you live outside of California, please see our Resources page for support groups who serve those in other states. Thank you.
Please click "submit" when you are through entering your information.
Comments and suggestions:
Copyright 2002-2003 California Heart Connection
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City
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Would you like to join our online support group? (If yes, we will send you instructions on how to access the group.)
How did you hear about us?
First Name:
Last Name:
Heart Patient's Name:
(write "self" if you are the heart patient.)
Heart Patient's Birthday:
Diagnosis:
Surgeries Performed:
(ex: Norwood, Glen, Fontan, etc.)
Hospitals Used:
Name of Cardiologist:
Name of Surgeon:
If heart patient is a child, list names and birthdays of siblings, if any:
