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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
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Patient's Name
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First Name
Last Name
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Address
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Address Line 1
Address Line 2
City
State
Zip
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Phone
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Patient's Gender
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Female
Male
Other
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Patient's Age
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Patient's DOB
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PATIENT'S MEDICAL HISTORY
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PATIENT'S MEDICAL HISTORY
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Name of Diagnoses
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(Copy from the ECHO Report)
Patient's first date of diagnoses
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Date of recent diagnoses
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*Upload the most recent ECHO Report
Current and past symptoms
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When did the symptoms start?
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What kind of treatment has the patient received?
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List ALL Current medications
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Patient's Pediatric Cardiologist Information
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Patient's Pediatric Cardiologist Information
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Pediatric Cardiologist Name
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Hospital or Clinic Name
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Hospitals or Clinic Address
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Hospital or Clinic Phone Number
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Email Address of Pediatric Cardiologist
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Parents Details
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Parents Details
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Mother
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Father
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Phone number
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Phone number
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Mother
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Father
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EMAIL
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EMAIL
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Mother
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Father
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Text Box
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