Paediatric Cardiothoracic Surgery Initiative (PCTSI) Application
If you are a Parent with a children in need of Surgery, please fill this form.
Email address
Patients name
Patient Gender
Patient Age
Patient DOB
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PATIENTS MEDICAL HISTORY
Name of diagnoses
(Copy from the ECHO Report)
Patients first date of diagnoses
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YYYY
Date of recent diagnoses
*Upload the most recent ECHO Report
MM
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YYYY
Current and past symptoms
When did the symptoms start?
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DD
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YYYY
What kind of treatment has the patient received so far?
List ALL Current medications:
Patient Pediatric Cardiologist Information
Pediatric Cardiologist Name
Hospital or Clinic Name
Hospital or Clinic Address
Hospital or Clinic Phone Number
Email Address of Pediatric Cardiologist
Parents Details
Mother
Father
Phone number
Mother
Father
EMAIL
Mother
Father
Address
Parent's Place of Employment
Name, Address, Position Held at job
Father Place of Employment Name
Position Held at Job
Address Place of Employment
Street
City
State
Country
Mother Place of Employment Name
Position Held at Job
Address Place of Employment
Street
City
State
Country
Emergency Contact
Phone Number
Home Address
Street
City
State
Country
Email Address
A copy of your responses will be emailed to the address you provided.
Please complete the captcha before submitting the form.
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