LHM Membership Form – Young person with a single ventricle heart

Bear in mind guys that if you're under 18 years your parents/carers need to be members too.

Your Name(Required)

First Last

Your Date of Birth(Required)

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

Email(Required)

Phone Number(Required)

Your ethnicity

Gender(Required)

Male

Female

Other

Prefer not to say

Your Diagnosis(Required)

Please give as much detail as possible here. If you are unsure about the diagnosis, what has your doctor / consultant said?

Please upload a copy of the first page of any clinic or hospital letter you have to confirm the diagnosis*(Required)

Max. file size: 10 MB.

Do you know which hospital you are treated at?(Required)

Do you know who your consultant is?(Required)

Do you know what surgery you have had or what stage of surgery you are at?(Required)

Are your parents also members of LHM?(Required)

Yes

If yes, what are their names?

Do you have any other information to share?

Would you like to be put in touch with someone who has shared similar experiences?(Required)

Yes

Main office