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:
      • 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.
  • 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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