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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Date of recent diagnoses *
*Upload the most recent ECHO Report
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Current and past symptoms *
When did the symptoms start? *
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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.
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This form was created inside of Hospitals for Humanity.