Patient Intake Form
Please fill out the following information about the patient so we can best assist you. Our advisory board of doctors will give second opinion on requests as soon as all medical reports have been received. Unless this is a medically urgent case, please allow a minimum of 7-14 days for a response.
Patient's First Name *
Your answer
Patient's Last Name *
Your answer
Email *
Your answer
Patient's Gender *
Patient's Date of Birth *
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Full Address
Your answer
Mobile Ph. No. *
Your answer
Who is the patient's current doctor/cardiologist? (Specify the names of all the doctors/cardiologists) *
Your answer
What hospital is the patient currently being seen at? *
Your answer
Describe the medical problem/diagnosis *
Your answer
What treatment is the doctor suggesting? Name any upcoming surgery and when it will be done. *
Your answer
What symptoms does the patient have?
Your answer
Does the patient have any other medical issues, besides heart? *
Your answer
What is the main question/concern do you have regarding patient’s health? *
Your answer
What surgeries have been done already and when was it done (month/year)?
Your answer
Is the child reaching his/her growth milestones? Rolling over, Grasping, Sitting up, Crawling, Vision and Hearing. *
Your answer
Patient's current height (inch/cm) *
Your answer
Patient's current weight (kgs/lbs) *
Your answer
Is the child feeding/eating well? *
Your answer
Is the child sleeping well? *
Your answer
How did you hear about Saloni Heart Foundation? *
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