Telehealth Form

Pediatric Heart Campaign
Patient Information Form

* Required Fields

Please remember to conversationally find out
the answers to the following questions and
include the answers in the Comments field:

If the mother is currently pregnant and if she is calling about her unborn child:

  1. Gestational age of the baby and mom's due date
  2. What is her baby's diagnosis, and when/by whom did she receive this diagnosis?

If the mother is calling about a baby or child:

  1. Age of the child
  2. What the child's diagnosis
  3. What treatment the child is currently receiving or has received in the past

Any other information that the mom shares. Taking notes throughout the call is great, even if it doesn't specifically fit into these questions.

We understand that information about you and your health is personal. We are committed to protecting your health information. View our privacy policy.