Medical Inquiry (Italiano)

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

IT Click to Proceed

IT Click here to proceed.

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IT Patient Information

IT Patient First Name ^* IT Please enter First Name

IT Patient Last Name ^* IT Please enter Last Name

IT Patient Date of Birth ^*

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

IT Patient Gender ^*

IT Please select a gender (male/female)

IT Other ^*

IT Patient Country of Residence ^*

IT Please enter a Country

IT Address Line 1 ^* IT Please enter Address Line 1

IT Address Line 2

IT City ^* IT Please enter a City

IT Patient's Preferred Language ^*

IT Please enter patient's preferred language

IT Does the Patient Speak English? ^*

IT Please indicate if the patient speaks English

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

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

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

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

IT Please indicate if a clinical summary is available

IT 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 ^*

IT Please indicate if imaging files are available

IT Parent/Guardian Information

IT Relationship to Patient ^*

IT Please select a relationship to patient

IT Other ^* IT Please enter the relationship to patient

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

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

Parent/Guardian Date of Birth ^*

IT Please enter a date of birth

IT Does the Parent/Guardian Speak English? ^*

IT Please indicate if English is spoken

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

IT Phone Number ^* IT Please enter a phone number

IT Country Code

IT Alternative Phone Number

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

IT Treating Physician or Primary Care Physician Information

IT Physician First Name

IT Physician Last Name

IT Hospital or Medical Institution

IT Country Code

IT Physician Phone Number

IT Physician Email

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

IT Drag files here or click to upload

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

IT Other Information

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

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

IT Relationship ^* IT Please provide the relationship

IT Email Address ^* IT PIlease provide the email IT PIlease provide the email

IT Payment Type ^*

IT Please choose a payment type

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

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

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

IT Staff member’s name.

IT Any additional information / comments?

IT 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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