Paediatric Cardiothoracic Surgery Initiative (PCTSI) Application

If you are a Parent with a Child in need of Open Heart Surgery, please fill this form.
Email *
Patient's Name *
First Name
Last Name
Address
Address Line 1
Address Line 2
City
State
Zip
Phone
Patient's Gender *
Patient's Age *
Patient's DOB *
PATIENT'S MEDICAL HISTORY
Name of Diagnoses *
(Copy from the ECHO Report)
Patient's first date of diagnoses *
Date of recent diagnoses *
*Upload the most recent ECHO Report
Current and past symptoms *
When did the symptoms start? *
What kind of treatment has the patient received? *
List ALL Current medications *
Patient's Pediatric Cardiologist Information
Pediatric Cardiologist Name *
Hospital or Clinic Name *
Hospitals or Clinic Address *
Hospital or Clinic Phone Number *
Email Address of Pediatric Cardiologist *
Parents Details
Mother *
Father *
Phone number
Mother *
Father *
EMAIL
Mother *
Father *
Text Box *
Parent's Place of Employment
Name, Address, Position Held at job
Father's Place of Employment Name *
Position Held at Job *
Address Place of Employment *
Street *
City *
State *
Country *
Mother's Place of Employment Name *
Position Held at Job *
Address Place of Employment *
Street *
City *
State *
Country *
Emergency Contact
Phone Number *
Home Address *
Street *
City *
State *
Country *
Email Address *