Kids With Heart NACHD, Inc. Disclaimer:

The intention of this information is to give parents of children with congenital heart disorders a place to find information about specific disorders and other support resources. Kids with Heart National Association for Children's Heart Disorders, Inc. personnel are not doctors or medical personnel. In no way should any information found on this site be a substitute to professional medical care or attention from a qualified practitioner nor should it be inferred as such. ALWAYS check with your child's doctor if you have any questions or concerns about any diagnosis, symptoms, or treatments.

Registration Form for Kids With Heart Nat'l Assoc. for Children's Heart Disorders

Registering to become a member of Kids With Heart is completly free! Registering with us will enable you to participate in the variety of services that Kids With Heart National Association for Childrens Heart Disorders has to offer. Just fill out the form below and check the services that interested you. Fill out as much information as you feel comfortable. When requesting parent matching services, a mailing address is required.

Note ~ Your personal information will not be released to solicitors or advertisers!

Parent's Name's:
 
Street Address:
 
City, State, Zip: 
E-mail address:  
Phone Number (include area code):  
How did you hear about Kids With Hearts:  
Heart Child (ren)'s Name(s):  
Child's Birth Date: (mm-dd-yr)  
Description of Heart Defect(s):  
POSTOP COMPLICATIONS:
Please check appropriate complications:
 SEIZURES
 PLEURAL EFFUSIONS
 PERICARDIAL EFFUSIONS
 STROKES
 HYDROCEPHALUS
 CHYLOTHORAX (Nicking Of Lymph Gland)
 CARDIAC ARREST
 HEMOLYSIS  
Other Medical Conditions:  
Surgery Date(s) and proceedures: (ex. repair of TOF, fontan, etc. 10/5/03) 
1.  
2.  
3.  
4.  
5.  
6.  
Cardiologist(s):  
Heart Surgeon(s):  
Hospital(s) Used:  
Would you go back - yes or no?
Helpful comments re: hospital

Helpful comments re: surgeon

Follow Up Care facility:  
Medications:  
Siblings & Their Birth Dates: (Brian 12-15-99)
1. 
2. 
3. 
4. 
5. 
6. 
Services Requested:
(Check Appropriate item(s) you wish to recieve.)
 	Information on a local group, if available in your area
 	Parent Matching - Matches parents of children with same CHD
	ACHD to ACHD Matching - Matches adults who have same CHD
 	ACHD to Parent Matching - Matches adults (ACHD) with parents of a child with same CHD as adult with CHD.
 	Meeting/Event Announcements (Green Bay Area Only)
 	Participating In Research Regarding Heart Defects
"X" indicates permission
 ___I give the Kids Heart National Association for Children's Heart Disorder, Inc. permission to release my name for the sole use of parent matching, research on heart defects, etc. 
Your personal information will not be released to any solicitors or advertisers!