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International Patient Registration Form

For coordination of appointments we will need a completed registration form and all related medical records (to include imaging, laboratory, etc.). Once information is completed and received, your case will be reviewed by the medical team. Please be advised that routine appointments are generally scheduled for 2-4 weeks after your case has been approved and a coordinator has been assigned. If you feel this is an urgent medical request requiring an appointment within two weeks, please contact Global Health directly for further assistance.

If you need to reach the Global Health Department, please call:
Local Phone: (305) 662-8281 or Toll-free: (888) 797-6010.

Patient Information


Patient Date of Birth (mm/dd/yyyy): *



Contact Information

Miami Address or Hotel (if available): *

Referral Information

Do you have a Primary Care Physician (PCP)? *
Do you have a Referring Physician? *

Parental Information

In order to authorize discussion of information with any individual who is not the patient’s parent/legal guardian, please complete and send the attached form to GlobalHealth@nicklaushealth.org. Please note that we will not be able to discuss any information with unauthorized individuals until the attached form has been received.

AUTHORIZATION FOR THE TREATMENT/DISCHARGE OF A MINOR
Parent 1 Date of Birth (mm/dd/yyyy): *
Parent 2 Date of Birth (mm/dd/yyyy): *

Financial Information

Do you have insurance? *

Clinical Information

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To expedite your request, we will need copies of the child's latest medical records (clinical summary containing history and current status, along with results of any recent tests).
You may upload the records here or Fax them to(305) 668-5586
Do you have in mind a specialist you would like to see at Nicklaus Children's Hospital? *

Preferred dates to visit:
(Please provide a two week range if possible)

Medical Information Consent:
By printing my name below I give consent to Nicklaus Children’s Hospital Global Health to share my child’s medical information among all physicians and medical personnel required to determine possible treatment and price estimates.

Preparer Information

Email Address:
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