Refer a child

Unfortunately, due to hospital bed limitations we are not able to accept any cardiac patients at present.

If you would like to refer a sick child to the Foundation there are a number of conditions. The child must be fifteen years or younger and must have an operable condition that cannot be treated in their home country.

Once this initial criteria is met you can complete the form below and submit it either electronically, or print it and send it to us at; 66 Chapman St, North Melbourne VIC 3051, AUSTRALIA.

Once the Foundation receives the Patient Request Form the child’s case is assessed by specialists as to the possibility of treatment. Hospital bed availability and surgeon’s operating schedules are also factors that are taken into account by the medical team.

Immigration, visas and accommodation can also impact on the timing of treatment for a child.
Patient Details
First Name*:   Surname*:  
Age/Date of Birth*:   Sex*:
Religion:
Nationality*:  
Language/s Spoken: Interpreter Req'd:
Home Address:
District/State:
Country:
Family Details
Father's Name:
Mother's Name:
Language/s Spoken: Interpreter Req'd:
Number of Siblings: Ages:
Contact Number:
Primary Care Giver Name: (if not parents e.g. grandmother)
Relationship to Child:
Alternative Phone Number: (e.g. neighbour, relative)
Consent of Parent/Primary Caregiver to Travel:
In exceptional circumstances a child may travel with ONE accompanying adult. Save in very exceptional circumstances, that accompanying adult MUST BE a female adult.

Referring Source Details
Name of Person or Organisation*:  
Contact Name*:  
Address*:  
Contact Number*:  
Fax Number:
Email Address:
Accompanying Adult Details
Name:
Nationality:
Address:
Contact Number:
Language/s Spoken: Interpreter Req'd:
*Proof of age must be submitted with this form for children who are 12 years or older. CFF will accept? the following documents as proof of age eg. Birth certificate, family certificate:
  • Certified copy of birth certificate of child
  • Certified copy of family certificate
  • Certified copy of any official document in the child's country of origin which is accepted in that country as proof of age
    • Medical Information and Reason for Referral
    Medical Condition Classification (please tick at least one):




    Reason for Referral/Diagnosis:
     
    Current Treatment and Medication:
    Details of Previous Surgery:
    Treating Doctor's Name and Contact Details:
    Any dietary restrictions for medical or religious reasons? (Note: We are unable to provide Halal meat)
    Additional Information
    Has the child ever received a blood transfusion?
    Family History:
    Diabetes
    Heart Conditions
    Unexplained death of children
    Is the child able to walk?
    Please provide a list of any relevant pathology, medical reports and imaging that is available for this patient. You will be asked to submit this information if your request is accepted to undergo a detailed medical assessment.

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