Mended Hearts, Inc.

Mended Little Hearts Parent-Matching Program

AUTHORIZATION FOR DISCLOSURE OF HEALTH INFORMATION
In order to provide you with more support, Mended Little Hearts will be happy to match you with families of children with heart defects in your area and/or online with families and caregivers who have children with a similar defect(s) as your child has or as you have. If you would like to be part of Mended Little Hearts parent-matching program, please fill in this form authorizing us to share your contact information with others in the program or who enter the program. Your information will NOT be used for any purpose other than parent matching.

By filling out this information, you are allowing Mended Little Hearts to share this information with anyone who has signed up under Mended Little Hearts parent-matching program. If you at any time would like to be removed from Mended Little Hearts' parent matching database, please send an email requesting removal to mlh@mendedlittlehearts.org and you will be removed.

It is Mended Little Hearts' policy not to give medical advice to those looking for support. Sharing experiences is a wonderful way of giving support, but giving medical advice is reserved for the patient's healthcare professionals. By filling out this form, you are agreeing not to give any medical advice to those to whom you provide support.

Finally, if you become aware of anyone who is misusing the parent-matching program in any way, please notify us immediately.

Please fill out the form below:

	* Required
* Full name:
* E-mail:
* Address:

* City:
* State:
* Zip:
* Phone:
Name of child: (if applicable)
* Diagnosis:
Surgeries or procedures:
Age of child: (if born)
Your age: (adults w/ CDH)
Please check all that apply:
	I would like to be matched with any families or caregivers of children with heart defects in my geographic area.
	I would like to be matched with adults with a similar heart defect.
	I would like to be matched with families or caregivers who have children with the same or a similar defect as my child.
	I would like information on forming a Mended Little Hearts group in my community.
*Thoughts and opinions shared through this parent-matching service do not necessarily reflect the opinions of Mended Little Hearts or Mended Hearts. Click here to become a member of Mended Little* Hearts.

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