Occasionally, members wish to get in touch with others who have similar circumstances. May we release your information to other members of California Heart Connection? (We only give names and email address and/or phone numbers, and never to anyone other than CA Heart Connection members.)
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 click "submit" when you are through entering your information. Thank you for joining California Heart Connection!
Comments and suggestions:
Copyright 2002-2016 California Heart Connection
Would you like to join our free online support group? (If yes, please take note of the instructions you receive once you hit the "submit" button or see below.)
How did you hear about us?
Name of Cardiologist:
Name of Surgeon:
If heart patient is a child, list names and birthdays of siblings, if any:
Heart Patient's Name: (write "self" if you are the heart patient.)
Telephone Number with Area Code:
Alternate Email Address:
Is heart patient deceased?
If applicable, please tell us the name of the physician or hospital that referred you to us.
Alternate Telephone Number:
Note: To keep costs down, we update our members on important information and events primarily via email. Please supply us with email addresses that you use most often, and let us know if your email address changes. Thank you!
Heart Patient's Birthdate:
(or due date)
Other Hospital used:
Procedures/Surgeries performed or expected in the future:
- You many release my information
- Please do NOT release my information
- Not at this time
ONLINE SUPPORT GROUP INSTRUCTIONS:
1. Go to: http://groups.yahoo.com/group/caheartconnection/ and sign in using the same email address you listed on the membership form. (PLEASE NOTE: The support group will not recognize any email address other than the one listed on your membership form.)
2. You will receive a notice when you have been added, along with a set of guidelines for the online support group. Then, you will be able to post to the group.