'It's My Heart' Order Form

It's My Heart is distributed free of charge to parents, loved ones, patients, health care professionals and support group leaders through the continued generous support of The Medtronic’s Foundation. Currently a maximum of two copies can be ordered per month. Copies of It's My Heart distributed free of charge may not be sold.

Shipping Information

Number of copies:	*
Language:
Spanish version currently unavailable. Please check back soon.
Prefix:
First Name:	* Required
Last Name:	* Required
Hospital/Clinic:
Support Group:
Department or Floor:
Notice: orders cannot be shipped to PO Boxes.
Street 1:	* Required
Street 2:
City:	* Required
State:	* Required
ZIP:	* Required
Country:	Shipments to US addresses only
Phone:	* Required
E-mail address:	* RequiredInvalid e-mail address

* Required field

Additional Information (optional)

Person(s) with CHD:
Husband:	Son:	Other:
Wife:	Daughter:
Self:	Friend:

I am interested in learning more about
being a CHF Advocate so that my voice can be heard by Congress.
becoming involved in a CHF chapter.
becoming a CHF Support Volunteer and helping other families
cope with a CHD diagnosis.

I would like to receive the CHF newsletter.
I would like periodic CHF e-mail updates.

Additional info / comments: (limit 200 words: )

The Children's Heart Foundation is a not-for-profit organization that funds the most promising research to advance the diagnosis, treatment and prevention of congenital heart defects.

The information in ChildrensHeartFoundation.org is not intended as a substitute for medical professional help or advice but is to be used only as an aid in understanding congenital heart disease.

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