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

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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 Year

Patient Gender ^*

Please select a gender

Address Line 1 ^* Please enter Address Line 1

Address Line 2

City ^* Please enter a City

State ^*

Please select a State

ZIP Code ^* Please enter your ZIPcode

Country ^*

Please enter a Country

Primary Diagnosis Conditions ^* Please enter one or more Condition (Maximum characters: 4000) You have {{pc.maxConditionLength - pc.Condition.length}} characters left.

Patient's Spoken Language ^*

Please select a language

If other ^* Please enter other language spoken

Parent/Guardian Information

Guardian ^*

Please select a Guardian Type

Guardian - Other ^*

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 valid Date of Birth

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

Confirm Email Address ^* Enter a valid email address in name@email.com format Please enter an Email Address Email addresses do not match

Country Code ^* Please enter a Phone Number Country Code

Phone ^* Please enter a Phone Number

Phone Type ^*

Please enter a Phone Number

Country Code

Alternative Phone

Alternative Phone Type

Address Line 1 ^* Please enter an Address

Address Line 2

City ^* Please enter a City

State ^*

Please select a State from the provided list

ZIP Code ^* Please enter a valid ZIPcode

Country ^*

Please enter a Country

Payment & Physician Information

Payment Source ^*

Please choose a Payment Source from those listed

Other Payment Source ^*

Primary/Referring Physician First Name ^* Please enter First Name

Primary/Referring Physician Last Name ^* Please enter Last Name

Primary/Referring Physician Email Address The email address provided is invalid

Country Code ^* Please provide physician's phone number country code

Primary/Referring Physician Phone Number ^* Please provide physician's phone number

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

Yes

Please indicate whether or not you have an electronic copy of the patient's medical records

How did you hear about Nationwide Children's Hospital?

Have you already been communicating with a Nationwide Children’s staff member ? ^*

Yes

Please indicate whether or not you have been communicating with a Nationwide Children’s staff member

Please provide the full name of the staff member. ^* Please enter full name of the staff member.

Tell us about your question ^* Please enter a question before continuing

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 (614) 355-3450 opt. 2 or email GlobalPatientServices@NationwideChildrens.org during normal business hours Mon-Fri 8:00am-4:00pm.

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International Medical Inquiry

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Patient Information

Parent/Guardian Information

Payment & Physician Information

Thank you for your medical inquiry