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 *
Your answer
Patient Gender *
Patient Age *
Your answer
Patient DOB *
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PATIENTS MEDICAL HISTORY
Name of diagnoses *
(Copy from the ECHO Report)
Your answer
Patients first date of diagnoses *
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DD
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YYYY
Date of recent diagnoses *
*Upload the most recent ECHO Report
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DD
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YYYY
Current and past symptoms *
Your answer
When did the symptoms start? *
MM
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DD
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YYYY
What kind of treatment has the patient received so far? *
Your answer
List ALL Current medications: *
Your answer
Patient Pediatric Cardiologist Information
Pediatric Cardiologist Name *
Your answer
Hospital or Clinic Name *
Your answer
Hospital or Clinic Address *
Your answer
Hospital or Clinic Phone Number *
Your answer
Email Address of Pediatric Cardiologist *
Your answer
Parents Details
Mother *
Your answer
Father *
Your answer
Phone number
Mother *
Your answer
Father *
Your answer
EMAIL
Mother *
Your answer
Father *
Your answer
Address *
Your answer
Parent's Place of Employment
Name, Address, Position Held at job
Father Place of Employment Name *
Your answer
Position Held at Job *
Your answer
Address Place of Employment *
Your answer
Street *
Your answer
City *
Your answer
State *
Your answer
Country *
Your answer
Mother Place of Employment Name *
Your answer
Position Held at Job *
Your answer
Address Place of Employment *
Your answer
Street *
Your answer
City *
Your answer
State *
Your answer
Country *
Your answer
Emergency Contact
Phone Number *
Your answer
Home Address *
Your answer
Street *
Your answer
City *
Your answer
State *
Your answer
Country *
Your answer
Email Address *
Your answer
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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