Smart Patients Pilot Project - Registration

Please complete the following information. If you have any questions, please contact Amy at info@conqueringchd.org

Question Title

1. The following information is required for you (the parent):

Name *

Address

City/Town *

State/Province *

ZIP/Postal Code *

Email Address *

Phone Number *

Question Title

2. Please list your child's primary heart related diagnosis:

Question Title

3. Please list the age of your child:

Question Title

4. What is the date of your next appointment?

Question Title

5. Please rate your comfort level with social media:

Not at all comfortable

Comfortable

Very Comfortable

Not at all comfortable

Comfortable

Very Comfortable

Question Title

6. Which answer best describes how often you use social media?

Never

Less than once a week

A few times a week

Once a day

Several times a day

Never

Less than once a week

A few times a week

Once a day

Several times a day

Thank you for completing our registration for the Smart Patients Pilot Project. You will be contacted in the next 1-2 weeks about your participation.

Your information will be securely stored and not shared outside of the Pediatric Congenital Heart Association.
Completion of this registration will automatically enroll you into our 1Voice/40,000 Strong Campaign through which you will be considered a partner of PCHA and recieve occasional traditional and electronic mailings. You may opt out of these mailigns at any time by emailing info@conqueringchd.org, or simply selectiing unsubscribe on any of our emails.