Heart Mask Request Form

Request homemade heart masks for your child. Simply complete the form below and two masks will be sent to the address you specify within 1-2 weeks.

Shipping Information

Full Name:(required)
Shipping Address:(required)
Phone:(required)
Email:(valid email required)
Your contact information will only be used for completing your order unless you respond below that you would like to receive more information.

Patient's Information

Full Name:
Age:
Medical Diagnosis:
Relationship to Patient:

Request

Mask Size:
Mask sizes are measured across the face over the nose where the patient would wear the mask. Use a measuring tape to measure from the cheek in front of one ear, over the nose, and to the cheek in front of the other ear.
Medical Recommendation for wearing a mask:
Please provide any additional information that will help us send masks the patient will like (favorite color, cartoon character, sports team, other theme):

How did you know?

How did you hear about our masks?
Would you like to receive more information about It's My Heart?
Yes, please. No, thank you.

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DID YOU KNOW?

Nearly twice as many children die from Congenital Heart Defects in the United States each year as from all forms of childhood cancers combined.

Yet funding for pediatric cancer research is 5 times higher than funding for Congenital Heart Defects.

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