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. Please be patient, due to high demand we are a little behind getting all the masks out!

PLEASE NOTE: MASKS CAN ONLY BE SENT WITHIN THE UNITED STATES.

Contact Information

Name:(required)
Address:(required)
City:(required)
State/Providence:(required)
Zipcode/Postal Code:(required)
Country:
Phone:
Email:(valid email required)

Patient Information

Gender:
Male Female
Birthdate:(required)
What size mask?
BABY: 6 1/2 inches wide X 6 1/4 inches long SMALL: 7 1/2 inches wide X 7 1/2 inches long MEDIUM: 7 1/2 inches wide X 8 inches long LARGE: 7 1/2 inches wide X 8 1/2 inches long
Patient Preferrences. Please list any characters, sports, or interests that will help us send the appropriate patterned mask.
Though we are an organization that supports people living with Congenital Heart Disease, it’s our pleasure to provide support to people living with other medical conditions as well. We ask that you provide your medical condition for our knowledge of the communities we’re serving.
Medical Need:(required)

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Heart Mask Request Form

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