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First Name
Last Name
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No
Are you a Parent or Guardian?
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No
Are you a CHD survivor?
Child or Children's First Name
Child or Children's Last Name
Date of Birth or Expected Date of Birth
If your child is an angel, date of their passing
HRHS Diagnosis (Ex. Tricuspid Atresia, PA / IVS, Pulmonary Stenosis, DILV, DOLV)
Surgeries waiting on
Surgeries and dates (or year(s)) performed
Hospital Name
Hospital Address (can be just City and State)
Surgeon's Name
State (or region, if outside of USA) of Residence
Country of Residence
E-mail Address
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