Tell us Your Story
Email address *
Title
First Name *
Your answer
Middle Names
Your answer
Surname *
Your answer
Address
Your answer
Postcode
Your answer
Telephone Number(s) *
Your answer
E-Mail Address *
Your answer
Are you a: *
Child's Name
If this story is not about yourself.
Your answer
Name of Heart Condition
What is the name of the heart condition(s)?
Your answer
Date of Diagnosis
approximate if not known
Your answer
The story so far *
As regards treatment and a brief account of your story.
Your answer
Title of Story
if you have a particular title you'd like us to use to describe your story, please enter it below.
Your answer
How may we use your story?
Would you be happy to do the following media:
Relating to your story or other relevant campaigns and projects (please tick all that apply)
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