International Medical Inquiry

If you live internationally and are interested in learning more about how you can bring your child to Nationwide Children's Hospital for medical care, please fill out the appropriate form below. A Global Patient Services representative will contact you to start the process.

If you have difficulty completing this form, please contact us at GlobalPatientServices@NationwideChildrens.org

Click to Proceed

Click here to proceed.

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Patient Information

Patient First Name ^* Please enter First Name

Patient Last Name ^* Please enter Last Name

Patient Date of Birth ^*

Please enter a valid date (MM/DD/YYYY) for Date of Birth

Patient Gender ^*

Please select a gender (male/female)

Other ^*

Patient Country of Residence ^*

Please enter a Country

Address Line 1 ^* Please enter Address Line 1

Address Line 2

City ^* Please enter a City

Patient's Preferred Language ^*

Please enter patient's preferred language

Does the Patient Speak English ^*

Please indicate if the patient speaks English

What is the Patient’s Primary Diagnosis ^* Please enter patient's primary diagnosis (Maximum characters: 4000) You have {{pc.maxConditionLength - pc.PrimaryDiaggnosis.length}} characters left.

Briefly Summarize Treatment received in the past ^* Please briefly summarize treatment received in the past (Maximum characters: 4000) You have {{pc.maxConditionLength - pc.PastTreatment.length}} characters left.

Briefly Explain Your Goal for Care ^* Please briefly explain your goal for care (Maximum characters: 4000) You have {{pc.maxConditionLength - pc.CareGoal.length}} characters left.

We need a current clinical summary detailing treatment history and patient’s current health status. Can you provide this information? ^*

Please indicate if a clinical summary is available

We may need radiographic imaging to review, do you have digital imaging available to upload? * If "Yes", Our staff will provide you with a link to upload imaging ^*

Please indicate if imaging files are available

Parent/Guardian Information

Relationship to Patient ^*

Please select the relationship to patient

Other ^* Please enter the relationship to patient

Parent/Guardian First Name ^* Please enter a first name

Parent/Guardian Last Name ^* Please enter a last name

Parent/Guardian Date of Birth ^*

Please enter a date of birth

Does the Parent/Guardian Speak English ^*

Please indicate if parent/guardian speaks English

Country Code ^* Please enter a phone number country code

Phone Number ^* Please enter a phone number

Country Code

Alternative Phone Number

Your Email Address ^* Please enter an email address Enter a valid email address in name@email.com format

Treating Physician or Primary Care Physician Information

Physician First Name

Physician Last Name

Hospital or Medical Institution

Country Code

Physician Phone Number

Physician Email

Do you have an electronic copy of the patient’s medical records (in English)?

Drag files here or click to upload

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Acceptable file formats: PDF, docx, JPG, PNG File size limit: 250 MB

Other Information

Is the person filling out this form either the parent or guardian? ^* If No, please provide relationship and email address.

Please indicate if the person filling out this form is either the parent or guardian

Relationship ^* Please provide the relationship

Email Address ^* Please provide the email Please provide the email

Payment Type ^*

Please choose a payment type

How did you hear about Nationwide Children’s Hospital?

Have you already been communicating with a Nationwide Children’s Hospital staff member? If yes, please list staff member’s name. ^*

Please indicate if you have you already been communicating with a Nationwide Children’s Hospital staff member.

Staff member’s name.

Any additional information / comments?

Thank you for your medical inquiry

Thank you for contacting Global Patient Services. We will reply to your message within 3 business days.

We are sorry, it appears that your request did not go through. Please call Global Patient Services at 1-800-829-4596 during the following hours 8:00 a.m. to 4:00 p.m.

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