Step 1 of 8 12% 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 which include but may not be limited to the following types of defects: Patent Ductus Arteriosis (PDA) Coarctation of the Aorta Atrial Septal Defect (ASD) Ventricular Septal Defect (VSD) Tetrology of Fallot (TOF) Have no chromosomal abnormalities. 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. Application Requirements: All requested information must be provided in order for the application to be considered by the Medical Review Committee. Missing information will delay the application until all necessary information is received. Please be sure to include the following when filling out the online application: Full legal name of the child Date of birth Current echocardiogram and report – Complete echocardiogram, including doppler images, performed within the past 3 months by a pediatric cardiologist or attending physician. We require a moving echocardiogram in DIACOM, MP4, or AVI format. No JPEG or still images will be accepted in place of the echocardiogram. The medical committee will not review a case without a moving echocardiogram. Photo of Child Current immunization record Test results for the following: TB Malaria Hepatitis B&C HIV Parasites (may be asked to retake tests before traveling) Sickle Cell ECG Chest X-ray Physicians letter detailing child’s health history and current physical examination. Any additional medical records you may have that will help the medical committee in reviewing your case. All materials requested must have been generated within the last 3 months. We have developed this protocol based on the conditions that our medical teams are willing to accept/treat. Our goal is to ensure a fair evaluation process and provide parents and children with realistic expectations once they submit the necessary information to us. Name of Child:* Diagnosis* Name of Care Giver:* Phone:*Email:* Country:* Language* Signature*Date MM slash DD slash YYYY By signing my legal name above, I acknowledge that I have read and understand the policies as contained herein. Name of Caregiver* Born On* DD slash MM slash YYYY Citizen of* Relationship to Child* Signature*Date* 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* DD slash MM slash YYYY Referred By* Contact Phone*Contact Email* Primary Diagnosis* Referring Physician* Physician Phone Number* Clinic/Hospital Name* Clinic/Hospital Phone Number* Medical History of Child*Parent, name, address, phone # & medical history*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 Syndromes Unrelated Cardiac Health Problems Psychological Problems Dental Problems Nutritional Problems None Other (list at right) Other Unrelated Cardiac Health Problems Height* Weight* Oxygen Saturation* IMMUNIZATIONS GIVENImmunization GivenDate Covid-19 VaccineVaccination Date Today's Date* 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* DD slash MM slash YYYY Social HistoryMedical issues of the traveling caregiver and any current medications the caregiver takes, if applicable FATHERName* Date of Birth* 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* DD slash MM slash YYYY Occupation* Religious Preference Child will be traveling with (1 caregiver):*NameRelationship to ChildAny 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* DD slash MM slash YYYY Patient and Caregiver Hold Harmless AgreementChild Name* Date of Birth* 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* 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* DD slash MM slash YYYY Certification of Patient Condition By Referring PhysicianI am referring:* Name of ChildDiagnosis* DefectHeartGift'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 which include but may not be limited to the following types of defects: Patent Ductus Arteriosis (PDA) Coarctation of the Aorta Atrial Septal Defect (ASD) Ventricular Septal Defect (VSD) Tetrology of Fallot (TOF) Have no chromosomal abnormalities. 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* Phone NumberPatient Clinic or Hospital Name, PhoneSignature*Country of Origin* Date* 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. Medical Documentation Full legal name of the child Date of birth Current echocardiogram and report – DVD of a complete echocardiogram, including doppler images, performed within the past 3 months by a pediatric cardiologist or attending physician. We require a moving echocardiogram in DIACOM, MP4, or AVI format. No JPEG or still images will be accepted in place of the echocardiogram. The medical committee will not review a case without a moving echocardiogram. Photo of Child Current immunization record Test results for the following: TB Malaria Hepatitis B&C HIV Parasites (may be asked to retake tests before traveling) Sickle Cell ECG Chest X-ray Physicians letter detailing child’s health history and current physical examination. Any additional medical records you may have that will help the medical committee in reviewing your case. (this one not mandatory) All materials requested must have been generated within the last 3 months. If child is able to walk or crawl, please attach a video of them being active. Photo of Child* Drop files here or Select files Accepted file types: jpg, jpeg, gif, png, pdf, tiff, Max. file size: 50 MB. Medical Documentation* Drop files here or Select files Accepted file types: jpg, gif, png, pdf, doc, docx, jpeg, Max. file size: 50 MB. If available, please attach the following: -Current echocardiogram and report (a moving video taken within the last 3 months) -Current immunization record • Current echocardiogram and report • Photo of Child • Current immunization record • Test results for the following: -TB -Malaria -Hepatitis B&C -HIV -Parasites (may be asked to retake tests before traveling) -Sickle Cell • ECG • Chest X-ray • Physicians letter detailing child’s health history and current physical examination. • Any additional medical records you may have that will help the medical committee in reviewing your case. (THIS ONE NOT MANDATORY)You can also share the Echocardiogram to [email protected] through Dropbox or Google Drive.Signature* Conditions for CaregiversIf child is selected 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 as a gift. In return for this gift we expect both the child and caregiver to honor the time, belongings and rules of HeartGift staff, physicians, host families, and volunteers. Conditions for Caregivers* I will return to my country immediately upon completion of the child’s medical treatment and under no circumstances will the child or I attempt to stay in the United States beyond the time needed for medical care. I certify that I am not pregnant I certify that I am in good health, and that I will not seek medical treatment for myself while in the U.S. I and the child will treat HeartGift staff, physicians, host families, and volunteers with respect and courtesy. I and the child agree not to travel apart from the host family, HeartGift staff, and/or volunteers. Neither I nor the child will engage in any other outside personal activities, including visits to or by friends or family in the United States, Canada and Mexico. I and the child understand that I am not permitted to communicate with any family members or friends living in the United States, Canada and Mexico without the express permission of HeartGift staff. I and the child will leave all original travel documents including my passport, visa, and tickets with a HeartGift staff person until medical treatment is complete and it is time to return home. Neither I nor the child will not change the status of my visa in any manner nor seek asylum while I am in the United States I understand that the child and I must abide by all State, U.S. Immigration Laws, Criminal Laws, and Civil Laws while in the United States. Should any of these conditions be violated, I understand that the child and I will be disqualified for the HeartGift program and will be sent home immediately. If at any time I become incapacitated for any reason, then I and the child may have to return to my country immediately even if it means that the child will not receive treatment. I acknowledge that all of the conditions in this Agreement have been read to me through an interpreter in my native tongue and I understand each condition and I accept all of the conditions. Please read and check all the boxes to agree to the conditions in this Agreement. Signature*By signing below, I hereby testify that I have read, understood and agree to these conditions.Emergency Contact of someone in home country:Name First Last Email Phone
