Medical Inquiry (Francais)

If you have a question about your child's health, but are not ready to request an appointment, please complete the form below. Our welcome service team will be happy to connect you with a Nationwide Children's expert to get you the advice you need.

Please note: If you are not the parent or legal guardian of the child for which you're inquiring, we will need a signed consent form prior to communicating about the child.

Please tell us a little about yourself and the patient:

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

FR Click to Proceed

FR Click here to proceed.

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FR Patient Information

FR Patient First Name ^* FR Please enter First Name

FR Patient Last Name ^* FR Please enter Last Name

FR Patient Date of Birth ^*

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

FR Patient Gender ^*

FR Please select a gender (male/female)

FR Other ^*

FR Patient Country of Residence ^*

FR Please enter a Country

FR Address Line 1 ^* FR Please enter Address Line 1

FR Address Line 2

FR City ^* FR Please enter a City

FR Patient's Preferred Language ^*

FR Please enter patient's preferred language

FR Does the Patient Speak English? ^*

FR Please indicate if the patient speaks English

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

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

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

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

FR Please indicate if a clinical summary is available

FR 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 ^*

FR Please indicate if imaging files are available

FR Parent/Guardian Information

FR Relationship to Patient ^*

FR Please select a relationship to patient

FR Other ^* FR Please enter the relationship to patient

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

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

FR Parent/Guardian Date of Birth ^*

FR Please enter a date of birth

FR Does the Parent/Guardian Speak English? ^*

FR Please indicate if English is spoken

FR Country Code ^* FR Please enter a phone number country code

FR Phone Number ^* FR Please enter a phone number

FR Country Code

FR Alternative Phone Number

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

FR Treating Physician or Primary Care Physician Information

FR Physician First Name

FR Physician Last Name

FR Hospital or Medical Institution

FR Country Code

FR Physician Phone Number

FR Physician Email

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

FR Drag files here or click to upload

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

FR Other Information

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

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

FR Relationship ^* FR Please provide the relationship

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

FR Payment Type ^*

Please choose a payment type

FR How did you hear about Nationwide Children’s Hospital?

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

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

FR Staff member’s name.

FR Any additional information / comments?

FR Thank you for your medical inquiry

Thank you for contacting Nationwide Children's Hospital. Someone should be in touch in the next three 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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