Refer a Child

Step 1 of 8

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:
- 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:
- 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.

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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.

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Social History
Medical issues of the traveling caregiver and any current medications the caregiver takes, if applicable
FATHER
Name*
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.)
MOTHER
Name*
Date of Birth*
DD slash MM slash YYYY
Occupation*
Religious Preference
Child will be traveling with (1 caregiver):*
Name Relationship 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*
DD slash MM slash YYYY

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Patient and Caregiver Hold Harmless Agreement
Child 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 Signature
Date*
DD slash MM slash YYYY

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Certification of Patient Condition By Referring Physician
I am referring:*

Name of Child
Diagnosis*

Defect
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:
- 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 Number
Patient Clinic or Hospital Name, Phone
Signature*
Country of Origin*
Date*
DD slash MM slash YYYY

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Child Information Uploads
Your 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:
- 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

Accepted file types: jpg, jpeg, gif, png, pdf, tiff, Max. file size: 50 MB.
Medical Documentation*
Drop files here or

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*

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Step 1 of 8

HeartGift's medical selection criteria includes:

Application Requirements:

Medical History

TESTED FOR

Social History

FATHER

MOTHER

Patient and Caregiver Hold Harmless Agreement

Certification of Patient Condition By Referring Physician

HeartGift's medical selection criteria includes:

Child Information Uploads

Medical Documentation

Conditions for Caregivers

Emergency Contact of someone in home country:

CHAPTERS

PARTNERS

GET INVOLVED

Immunization Given	Date

Vaccination Date