Step 1 of 7 14% Name of Child:*Diagnosis:*Defect 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:*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. * 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 will treat my hosts with respect and courtesy for what they are providing for the child. I agree not to travel apart from the host family or engage in any other outside personal activities, including visits to or by friends or family in the United States, Canada and Mexico. I understand that I am not permitted to communicate with any family members or friends living in the United States without the express permission of HeartGift. I 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. I 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 U.S. Immigration Laws, Criminal Laws, and Civil Laws while in the United States. I certify that I am not pregnant, that I am in good health, and that I will not seek medical treatment for myself while in the U.S. Should any of these conditions be violated, I understand that Child will be disqualified for the HeartGift program. 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*Date of Birth* Date Format: DD slash MM slash YYYY Country & Language*Referred By*Contact Phone*Contact Email* Primary Diagnosis*Referring Physician*Secondary DiagnosisMedical History of Child*Parent, name, address, phone # & medical history*Medical Problems*Previous SurgeriesPost-op & follow-up care available with physician?*Other (schooling, pets)*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 Scabies Lice *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 HistoryName of Child*Age*Address*Country*AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSaint MartinSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabweSex*Telephone*Language(s)*FATHERName*Date of Birth* Date Format: DD slash MM slash YYYY Occupation*Religious PreferenceMOTHERName*Date of Birth* Date Format: DD slash MM slash YYYY Occupation*Religious PreferenceCHILD WILL BE TRAVELING WITH*NameRelationship to Child SIBLINGSNameAge FAVORITESToysFoods Childs School / GradeChild does not likeAny 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. We need: -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-rayUpload Echocardiogram* Drop files here or Accepted file types: wmv, avi, mov, dcm, mp4, flv. Current video of echocardiogram that includes the entire anatomy of the heart including the entire defect and report that has been performed within the last 3 months.Link to Echocardiogram (if applicable)You can also share the Echocardiogram to [email protected] through Dropbox or Google Drive.
