refer a child

Submit a patient application

Guidelines for Patients in need of cardiac intervention

In order to be a candidate for surgery with Hearts of Joy International, the child must have Down syndrome and one of the following Heart Defects:

URL

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Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Child's Full Name(Required)

Country of Origin(Required)

Religion

Date of Birth(Required)

Age(Required)

Height(Required)

Weight(Required)

Gender(Required)

Mother's Name(Required)

Father's Name(Required)

Guardian Name (if applicable)

Child's Diagnosed Condition(Required)

Date of Diagnosis(Required)

Name of Cardiologist

Child and Family Medical History(Required)

Does the child have siblings? If so, please list names and ages(Required)

Previous Conditions or Surgeries(Required)

Allergies(Required)

Current Medications(Required)

Total Household Income (monthly)(Required)

Does the parent/guardian and child have a passport?(Required)

Yes

Have you applied for assistance from another non profit? If so, which one?(Required)

How did you hear about Hearts of Joy International?(Required)

Upload Medical Documents (including Echo Report and Chest X-Ray)

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Max. file size: 300 MB.

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