Step 1 of 7 14% Name of Child:*Diagnosis* HeartGift's medical selection criteria includes: The child be 14 years old or younger Not have undergone previous cardiac surgery Have a biventricular condition that can be repaired in one operation. Have no chromosomal abnormalities. Have an urgent need for surgery The child lives in a developing country without access to proper treatment. I hereby certify that all known and/or discernible health conditions are disclosed in the referring documents, e.g. suspected chromosomal disorders or other syndromes, immune deficiency, and any other diseases. Name of Care Giver:*Phone:*Email:* Country:*Language*Signature*Date Date Format: MM slash DD slash YYYY By signing my legal name above, I acknowledge that I have read and understand the policies as contained herein. The HeartGift Medical Selection Committee-consisting of pediatric cardiothoracic surgeons and pediatric cardiologists-reviews potential cases for treatment in the United States. We pledge to provide all necessary medical care related to his or her heart condition as well as housing, meals, and translation services for the child and caregiver completely free of charge. In return for this gift we expect both the child and caregiver to honor the time, belongings and rules of HeartGift staff, physicians, and volunteers. Name of Caregiver*Born On* Date Format: DD slash MM slash YYYY Citizen of*Passport Number (if applicable)Relationship to Child*Signature*Date* Date Format: DD slash MM slash YYYY By signing my legal name above, I acknowledge that I have read and understand the policies as contained herein. Medical HistoryName of Child*Sex of Child*Child's Date of Birth* Date Format: DD slash MM slash YYYY Referred By*Contact Phone*Contact Email* Primary Diagnosis*Referring Physician*Secondary DiagnosisMedical History of Child*Parent, name, address, phone # & medical history*Medical Problems*Previous Surgeries/ ProceduresPost-op & follow-up care available with physician?*KNOWN BIRTH DEFECTS AND/OR SYNDROMES Cleft Palate Trisomy 21 None Other (list at right) Other Know Birth Defects and/or SyndromesUnrelated Cardiac Health Problems Psychological Problems Dental Problems Nutritional Problems None Other (list at right) Other Unrelated Cardiac Health ProblemsHeight*Weight*Oxygen Saturation*IMMUNIZATIONS GIVENImmunization GivenDate Today's Date Date Format: DD slash MM slash YYYY TESTED FORTESTED FOR: TB HIV Hepatitis B Hepatitis C Scabies Lice Parasites Sickle Cell Disease Malaria *If you check TB, HIV and/or Hepatitis, test results will need to be attach with all other documentation.Allergies*Current Medications*Completed By*By signing my legal name below, I acknowledge that I have read and understand the policies as contained herein.Signature*Date* Date Format: DD slash MM slash YYYY Social HistoryMedical issues of the traveling caregiver and any current medications the caregiver takes, if applicableFATHERName*Date of Birth* Date Format: DD slash MM slash YYYY Occupation*Religious Preference (this information is used only in matching the child and caregiver with a host family)MOTHERName*Date of Birth* Date Format: DD slash MM slash YYYY Occupation*Religious PreferenceCHILD WILL BE TRAVELING WITH*NameRelationship to Child Any Reaction to Medication or Food?Completed By Name:*By signing my legal name below, I acknowledge that I have read and understand the policies as contained herein.Signature*Date* Date Format: DD slash MM slash YYYY Patient and Caregiver Hold Harmless AgreementChild Name*Date of Birth* Date Format: DD slash MM slash YYYY As the legal guardian accompanying (child referenced above) to the United States, the undersigned, on behalf of themselves, the patient and all who may claim through them, release the HeartGift Foundation, its directors, officers, employees, volunteers and attending physicians or other healthcare providers from any and all claims, demands, causes of action and suits, including, but not limited to, claims for negligence, gross negligence, invasion of privacy, defamation, breach of contract or other breach of duty arising out of or in connection with the use of this material. This information has been read by me or to me in my native language and I understand the contents of this release.Parent/Guardian or Legal Representative Name*By signing my legal name below, I acknowledge that I have read and understand the policies as contained herein.Signature*Date* Date Format: DD slash MM slash YYYY Witnessed / Interpreter Name*By signing my legal name below, I acknowledge that I have read and understand the policies as contained herein.Witnessed /Interpreter SignatureDate* Date Format: DD slash MM slash YYYY Certification of Patient Condition By Referring PhysicianI am referring:*Name of ChildDiagnosisDefect with the understanding that HeartGift’s medical selection criteria includes: Be under age 14. Not have undergone previous cardiac surgery. Have a biventricular condition that can be repaired in one operation. Have no chromosomal abnormalities. Have an urgent need for surgery. Have a strong chance of survival. This ensures that HeartGift meets its ethical responsibility to serve children who can go on to lead healthy lives after surgery with no need for follow-up care, given that HeartGift patients are from developing countries with little or no access to advanced medical care. I hereby certify that all known and/or discernible health conditions are disclosed in the referring documents, e.g. suspected chromosomal disorders or other syndromes, immune deficiency, and any other diseases. Physician Name*Signature*Country of Origin*Date* Date Format: DD slash MM slash YYYY Child Information UploadsYour referral will not be complete until you provide HeartGift with a picture and copy of an echocardiogram study for the child you are referring. If you prefer, you may mail the picture and echocardiogram study to HeartGift Foundation.Photo of Child* Drop files here or Accepted file types: jpg, jpeg, gif, png, pdf, tiff. Medical Documentation* Drop files here or Accepted file types: jpg, gif, png, pdf, doc, docx, jpeg. If available, please attach the following: -Current echocardiogram and report (a moving video taken within the last 3 months) -Current immunization record -Letter from referring physician detailing child's health history and current physical examination -ECG -Chest X-ray You can also share the Echocardiogram to [email protected] through Dropbox or Google Drive.SignatureUntitledFile
