International Patient Registration Form

In order to schedule appointments we first need a fully-completed registration form and all related medical records (including any imaging, laboratory, etc). Once Global Health receives all relevant information, your case will be reviewed by the medical staff. Be advised that routine appointments are generally scheduled for dates 2-4 weeks after your case has been initiated with a coordinator. If this is an urgent medical request requiring an appointment within two weeks, please contact Global Health directly.

If you need to reach the Global Health Department, please call:

Local Phone: (305) 662-8281 or Toll-free: (888) 797-6010.


Patient Information

Gender*:
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Have you read the Notice of Privacy Practices?*:
Please take a moment to read our Notice of Privacy Practices.

Contact Information

Referral Information

Do you have a Primary Care Physician?:
Do you have a Referring Physician?:

Parental Information

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Financial Information

Do you have insurance?*:

Clinical Information

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)

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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.

Would you be interested in a video conference (TeleHealth) with one of our specialists?(Physician in home country required for consult):
Medical Information Consent*:
I give consent to Nicklaus Children’s Hospital Global Health Services to share my child’s medical information among all physicians and medical personnel required to determine possible treatment and price estimates.