International Patient Registration Form

If you would like to have your child assessed at Nicklaus Children's Hospital, please complete the Global Health Patient Registration Form below.

Please Note: 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 at (305) 662-8281.

Patient Information


Contact Information

Permanent Country*:

Parental Information


Referral Information

Financial Information

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.

Please 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

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

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