International Patient Registration Form

If you need to reach the Global Health Department, you may reach them directly at:

Local Phone: (305) 662-8281

Toll-free: (888) 797-6010

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.

Please also print and complete the Consent for Release/Request Form and send it back to Global Health Services along with a copy of a picture ID (such as a Driver's License or Passport). You may fax it directly to 305-668-5586 or email it to

Patient Information


Contact Information

Permanent Country*:

Parental Information


Referral Information

Financial Information

Based on review of all medical records, our Global Health team will provide you a discounted cost estimate which will need to be paid prior to the service. This special rate is not valid for reimbursement with insurers or payers, as such NCH will not provide documentation (such as UB-04 or CMS 1500) required by payers for reimbursement. Please check here to confirm that you understand these terms.
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.

Services Requested

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.


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


If you have a visa, you must send a copy (parent & child) along with the questionnaire in order to provide a medical appointment with our specialist. If you require a letter to obtain the visa, please provide the phone number of the embassy where you are processing the visa. Once the medical information is received and reviewed, we will indicate the required deposit that will need to be paid in full prior to the patient coming to our institution. Please be advised, is the deposit indicated is not utilized, the hospital will make the reimbursement once the patient has returned to his or her country.


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