Shriners Hospitals for Children International Headquarters
Welcome! ¡Bienvenidos! !‫ ﻣﺮﺣﺒﺎ‬Bienvenu! Receber!
International Patient Program Family Guide
Part 1 of 3
Shriners Hospitals for Children was founded in 1922 with the goal of
providing expert medical care for children with no financial burden to
the patients or their families.
The Vision for SHC’s international strategy is to be the globally recognized
resource for specialty pediatric care, training, and research aimed at
maximizing every child’s potential. This is accomplished by treating more
children in more places, closer to their homes, building international
capacity, leveraging our brand, expertise, membership and core Shriners
mission and optimizing the use of our resources.
2900 N. Rocky Point Drive
Tampa, FL 33607
Referrals: 1-800-237-5055
Fax: 813-200-2782
Email: patientreferrals@shrinenet.org
Web: Shrinershospitalsforchildren.org
International Patient Request for Care Process
To guide you through the International Patient Request for Care Process please review the
following instructions. For any further questions or concerns please call/ email your assigned
International Patient Coordinator directly or contact us at patientreferrals@shrinenet.org. We
thank you for choosing Shriners Hospitals for Children for your child's care.
Step 1 of 3: International Request for Care & Clinical Review
- An
International Patient Referral Specialist will be assigned to your case and will
work with you to complete the required steps to evaluate your child's case for care at
Shriners Hospitals for Children.
- The
attached checklist includes all of the documents that must be submitted during the
first step of the process. If a document is not available, your assigned International
Patient Specialist will work with you to make accommodations if possible. If you need
assistance with completing any forms your International Patient Specialist will be able
to assist you.
- Your
child's clinical information will be reviewed by an SHC physician to see if we
can help and a clinical acceptance/ denial will be determined within 2 weeks and
communicated to you by your assigned International Patient Specialist.
International Patient Request for Care Checklist
Step 1of 3: Initial Documents for Clinical Review
International Request for Care Form
Authorization to Release Health Information
Email Use Agreement
Tele-health Use Consent
Medical History Questionnaire
Healthcare Professional Certification Form
Immunization Record
Clinical Records (In English)
Images/ Scans & Reports (In English)
Photos/videos of Patient Condition (with dates)
*Further documentation may be required at the request of SHC Physicians
INTERNATIONAL PATIENT
REQUEST FOR TREATMENT
Date:
To be completed by parent or guardian (please print)
1. Demographics (Required)
Child's Last Name*
Child's First Name*
Child's Date of Birth* (mm/dd/yyyy)
Gender*
Parent’s Marital Status
Married
Divorced
Male
Female
Unknown
Custody
Parents
Single
Widowed
* required fields
Child's Suffix
Child's Middle Name
Mother
Father
Preferred Language
Interpreter
Required?
Living with?
Case Manager
Grandparents
Other
No
Parents
Mother
Father
Yes
Grandparents
Other
Separated
Child's Home Address*
City*
Zip / Postal Code*
Country/Municipality
County
Child's Permanent Mailing Address (if different than home address)*
Zip / Postal Code*
State / Province*
Is home address the
mailing address?*
City*
Yes
No
State / Province*
Country/Municipality
Primary /Home
Number*
Alternate Phone Number
Home
Cell
Work
Pager
Email Address*
Other:
2. Medical Information (Required)
What is your child's medical problem or diagnosis:
Onset of
problem*
From Birth
* required fields
Developed Over time
Since Birth
Onset of walking
Developed recently
Injury, date unknown
Injury, Date Known
Date:
Other
What medical care or services are you looking for from the Shriners Hospitals for Children?*
What previous treatments have been provided?* (Treatments and surgeries, dates etc.)
Child’s walking
abilitiy
X-Rays available?
No
Yes
Walk unassisted
Walker
Date of most recent X-ray
Wheelchair
Crutches
Date last seen by physician
Cane
Other, specify

Please attach any other medical information you
have regarding this problem such as a physician
referral letter, or past medical records
3. How did you hear about Shriners Hospitals for Children?
Family Member
Friend
Other
01/2013
Other Health Care Professional
Other Media
Physician
School
Shriner
Television
Temple Screening Clinic
Website
At least one of sections 6, 7 or 8 must be completed.
Child's Name:
4. Physician Information if Available
Referring Physician (Last Name)
Referring Physician (First Name)
* required fields
Phone Number with Area Code/International Code
Referring Physician’s Office Address
City
State/Province
Zip/Postal Code
Country
Email Address
Email Address
Phone Number with Area Code/ International Code
5. Referring Temple/ Shriner if Applicable
Referring Temple/ Shriner
6. Mother’s Information
Legal Guardian's Last Name*
Legal Guardian's First Name*
Legal Guardian's Home Address*
Same as child's
Zip / Postal Code*
City*
Country
Primary Phone Number*
Legal Guardian's Middle Name
State / Province*
County
Home
Cell
Work
No Phone
* required fields
Suffix / Maiden Name
Date of Birth * (mm/dd/yyyy)
Email Address*
Other:
7. Father’s Information
Legal Guardian's Last Name*
Legal Guardian's First Name*
Legal Guardian's Home Address*
Same as child's
Zip / Postal Code*
City*
Country
Primary Phone Number*
Legal Guardian's Middle Name
State / Province*
County
Home
Cell
Work
No Phone
* required fields
Suffix / Maiden Name
Date of Birth * (mm/dd/yyyy)
Email Address*
Other:
8. Legal Guardian's Information (if different from parent)
Not applicable
Legal Guardian's Last Name*
Legal Guardian's First Name*
Legal Guardian's Home Address*
Zip / Postal Code*
Primary Phone Number*
Same as child's
Legal Guardian's Middle Name
City*
Country
State / Province*
County
Home
Cell
Work
No Phone
* required fields
Suffix / Maiden Name
Email Address*
Date of Birth * (mm/dd/yyyy)
Relationship to Child*
Other:
9. Sponsor Information if Applicable
Last Name*
* required fields
Address:
Zip / Postal Code*
Primary Phone Number*
City*
Country
Home
Work
Other:
01/2013
Organization Name:
First Name*
State / Province*
County
Cell
No Phone
Email Address*
Date of Birth * (mm/dd/yyyy)
Relationship to Child*
AUTHORIZATION TO RELEASE PROTECTED HEALTH
INFORMATION AND/OR CONTACT INFORMATION
Patient Name (please print): ____________________________________________________Date of Birth: ___________________
Patient Address: ____________________________________________________________________________________________
I agree to allow Shriners Hospitals for Children® (“Hospital”) to release information about me or my child
to Shriners International (“the Shriners”), the organization that founded Shriners Hospitals for Children and other organizations
which continue to support its mission, and that provides some free services to patients of the Hospital and their families.
By checking the box(es) below, I authorize the Hospital to release my, or my child’s, name, telephone number and
street address for the reasons set forth below:
To contact us or provide information about upcoming Shriners’ events.
To obtain services provided by the Shriners, such as transportation and to share information regarding my or my
child’s medical condition to the extent it is needed by Shriners in order to provide requested services, including information
created before and after this document is signed.
To obtain services provided by other non-governmental organizations and government agencies, such as
transportation and to share information regarding my or my child’s medical condition to the extent it is needed in order to
provide requested services, including information created before and after this document is signed;
I understand that by signing below:
•
I acknowledge that my signature is voluntary and I know that I do not have to sign this authorization to receive medical
treatment at the Hospital;
•
I may withdraw my consent in writing by contacting the Hospital Privacy Officer;
•
My withdrawal will be effective on the date it is received by the Hospital and will not affect the release of information
prior to receipt;
•
I understand the information that will be provided to Shriners may be shared by Shriners with others and may not be
protected by privacy regulations; and
•
This Authorization expires upon the minor’s age of majority.
If you have questions about this form, please ask to speak to the Hospital Privacy Officer. If you dial “0” on any
Hospital phone, the operator can page the Privacy Officer for you. You can also call Headquarters at (813) 281-0300 and ask to speak
with the Compliance Officer.
/
/
Signature of the Parent/Legal Guardian / Date
Signature of the Parent/Legal Guardian / Date
Print Name and Relationship to Patient
Print Name and Relationship to Patient
/
/
Signature of the Witness / Date
Signature of the Witness / Date
Name (Print)
Name (Print)
Patient Name & MR #:
SHC-US Hospitals
Revised 08/2021
Page 1 of 1
FOR USE BY THE SHRINERS HOSPITALS FOR CHILDREN AND SHRINERS
INTERNATIONAL PUBLIC RELATIONS DEPARTMENT AND THE PUBLIC RELATIONS
DEPARTMENTS OF THE FACILITIES OF SHRINERS HOSPITALS FOR CHILDREN
AUTHORIZATION TO USE NON-PATIENT'S LIKENESS FOR
MARKETING, PUBLIC RELATIONS, AND FUNDRAISING PURPOSES
I understand that Shriners Hospitals for Children® (“SHC”) is a charitable organization
which depends, in part, upon financial support from the public to operate its hospitals and that
Shriners International (“SI”) is a 501(c)(10) organization that supports SHC. I also understand that
SHC and SI engage in marketing, public relations, and fundraising programs designed to
publicize the availability of SHC’s services, promote interest and membership in SI, and the need
for continued financial donations and support.
I understand that by signing below, I am authorizing SHC and SI to use the first and last
name and photographs, slides, film, videotape, audiotape, motion pictures or other recordings
containing the image and/or voice of
(“Individual”),
who may either be me or the minor I am signing this form on behalf of, as part of SHC’s and SI’s
marketing, public relations, and fundraising programs (which programs may involve social
media).
I wish to help SHC and SI in their marketing, public relations, and fundraising programs,
and I consent to the production and use of the first and last name and photographs, slides,
videotape, audiotape, motion pictures or other recordings of the Individual or parts of the
Individual’s body, including but not limited to those taken at an SHC facility or at an SHC or SI
community or hospital function, for any marketing, public relations, and fundraising purposes.
I can revoke this authorization at any time by notifying SHC or SI in writing. However,
revoking this authorization will not affect the release of information which occurred prior to the
revocation.
I release any and all rights or claims for payment or royalties in connection with any
exhibition, print and broadcast advertising, television, broadcast on the SHC or SI intranet site or
the internet, digital distribution, or other showing of the motion pictures, videotapes, sound
recordings or photographs used in furthering SHC’s or SI’s mission.
I agree to hold harmless SHC, SI, and their affiliated corporations, the hospitals and all of
their personnel and volunteers, Shrine Temples, their officers, members and employees from any
and all liability related to the making or use of the photographs, slides, films, videotapes,
audiotapes, digital recordings, motion pictures or other recordings.
Shriners Hospitals for Children®
Shriners International
Authorization to Use Non-Patient’s Likeness for
Marketing, Public Relations, and Fundraising Purposes
Rev. 08/2014
Page 1 of 3
I hereby knowingly and voluntarily authorize SHC and SI to use such information for the
purposes described above.
Signature of Individual/Parent/Legal Guardian
______/______/_____________
Date
Print Name and Relationship to Individual
______/______/_____________
Date
Signature of the Witness
Witness (print name)
______/______/_____________
Date
Signature of Parent/Legal Guardian
Print Name and Relationship to Individual
______/______/_____________
Date
Signature of the Witness
Witness (print name)
Shriners Hospitals for Children®
Shriners International
Authorization to Use Non-Patient’s Likeness for
Marketing, Public Relations, and Fundraising Purposes
Rev. 08/2014
Page 2 of 3
Hospital/Public Relations Use Only
Individual Name: __________________________________________________________
Home Phone:
(______)___________ Work Phone: (_____)____________________
Email address:
________________________________________________________
If disclosing the Individual’s last name, please provide the following:
Nature of Publication (e.g., video, printed direct mailing):
Reason for Publication (e.g., fundraising, education):
Timeframe for Use and Disclosure of Individual’s Last Name:
Comments:
Shriners Hospitals for Children®
Shriners International
Authorization to Use Non-Patient’s Likeness for
Marketing, Public Relations, and Fundraising Purposes
Rev. 08/2014
Page 3 of 3
Email AUTHORIZATION AGREEMENT
FOR SHC AND PATIENT e-COMMUNICATION
This Agreement for SHC and Patient e-Communications ("Agreement") is entered into as of this
____ day of ___________________, 20____, between Shriners Hospitals for Children® ("SHC")
and ____________________________________ ("Patient").
SHC offers patients the ability to communicate with healthcare providers via electronic mail (email) for non-urgent matters, through a secured mechanism, if the arrangement is agreed to by
both Provider and Patient. SHC also offers patients the ability to communicate and receive nonclinical emails for purposes of receiving satisfaction surveys and other information relating to the
care you receive at SHC.
Use of Email Communications: Patient agrees and understands that Patient may use e-mail to
communicate with Patient's SHC healthcare provider ("Provider") regarding Patient's care and
treatment, and regarding certain administrative matters. However, Patient may not use instant
messaging or texting to communicate with your Provider. Patient shall not use e-mail to
communicate with the Provider for emergencies or other time-sensitive issues or inquiries which
deal with sensitive information. The types of information that can be communicated via e-mail
with the Provider include, but are not limited to, general medical advice after a face to face visit,
lab test results, patient referrals, appointment scheduling requests, and patient educational
material. If Patient is not sure if the issue should be included in an e-mail to the Provider, Patient
will call Provider's office to schedule an appointment. In the event of emergency, call 911 or
go to an emergency room, urgent care or immediate care facility. E-mail communications
may be documented in your medical record by placing a copy of the message in your record, as
determined by your provider as clinically relevant for such inclusion.
Sending E-mails:
You must include the patient’s full name, address, and medical record ID number in every e-mail
message that you send to your Provider. This information is required so the physician can
establish that the patient requesting medical advice is in fact the person the sender claims to be.
Without this information, the physician will not be able to address your questions. The subject of
the e-mail should include the purpose of the email, for example: “Verify appointment”. If you
receive a message from your provider containing important medical advice, acknowledge the
message by sending a brief reply. If your provider does not respond to your email in 2 business
days, contact the provider’s office.
Alternate Forms of Communication: Patient understands that he/she may also communicate
with the Provider via telephone or during a scheduled appointment and that the e-mail is not a
substitute for the care that may be provided during an office or hospital visit. Appointments
should be made to discuss any new issues as well as any sensitive medical information.
Risks of Using E-mail to Communicate with Provider: Transmitting patient information by email has a number of risks that Patient will consider before using e-mail to communicate with the
Provider. SHC does not guarantee the privacy or security of any messages being sent over the
Internet. Some risks include, but are not limited to, the following:
• E-mail can be circulated, forwarded and stored in numerous paper and electronic files.
• E-mail can be immediately broadcast worldwide and be received by unintended recipients.
*TEC005C*
TEC.005c Rev 11/2018
Patient Information Label
Page 1 of 2
•
•
E-mail AUTHORIZATION AGREEMENT
FOR SHC AND PATIENT e-COMMUNICATION
E-mail senders can easily type in the wrong e-mail address.
E-mail can be used to introduce viruses into computer systems.
Security Measures Taken by SHC: SHC uses the following security measures, among others,
to ensure the security of protected health information ("PHI").
• Patient-identifiable information is never forwarded to a third party, except for diagnosis,
treatment, other related reasons, or healthcare operations purposes, without the Patient's
permission.
• Patient's e-mail addresses are never used for marketing purposes without the Patient's
permission.
• Professional e-mail accounts are not shared with patient's family members.
Hold Harmless: Patient agrees to indemnify and hold harmless the Provider, SHC, and its
trustees, officers, directors, employees, agents, and information providers, from and against any
and all losses, expenses, damages and costs, including reasonable attorney fees, relating to or
arising from any information loss due to technical failure, Patient's use of the internet to
communicate with the Provider, the use of the Provider's website, any arrangements Patient
makes based on information obtained at the site, and any breach by Patient of these restrictions
and conditions. The Provider does not warrant that the functions contained in any materials
provided will be uninterrupted or error-free, that defects will be corrected, or that the Provider's
website or server that makes such site available is free of viruses or other harmful components.
Termination of E-mail Relationship: Patient has the right to revoke this consent, in writing, at
any time by presenting the written revocation to Provider. The Provider shall have the right to
immediately terminate the e-mail relationship with Patient if Provider so determines, in Provider's
sole discretion, that Patient has violated the terms and conditions set forth in the Agreement or
has engaged in conduct which the Provider determines to be unacceptable.
Patient Acknowledgment and Agreement: Patient has been informed of and understands the
risks and procedures involved with using email, and consents, under the terms described herein,
to the use of e-mail, as one means of communication between Patient and SHC Provider, and
his/her associates, technicians, and other health care providers.
_______________________________________________________ Date: __________ Time: _________
Signature of Father or Legal Guardian
_______________________________________________________ Date: __________ Time: _________
Signature of Mother or Legal Guardian
________________________________________________________ Date: __________ Time: _________
Signature of patient (14 years or older)
Witnessed By: ____________________________________________ Date: _________ Time: __________
Email Address: _________________________________
Patient Information Label
TEC.005c Rev 11/2018
Page 2 of 2
Informed Consent for Telehealth Services
Telehealth Facility Name: ______________________________________________________________
Patient Name: _______________________________________________________________________
Patient Date of Birth: __________________________________________________________________
I, or the undersigned, as the parent(s) or legal guardian of
understand
(Print Name of Patient)
1. I, or (if the undersigned is the parent or legal guardian of the patient) my child, may receive telemedicine or
telehealth (hereinafter collectively “Telehealth”) services from Shriners Hospitals for Children and/or its staff
(hereinafter “SHC”) at an offsite clinic location, or directly through access provided by the SHC patient portal or
other electronic means.
2. I understand that audio or video conferencing technology will be used and that Telehealth services will not be
the same as a direct patient-health care visit because the health care provider will not be in the same room with
me, or my child, as applicable.
3. A record of the Telehealth services will be included in my or my child’s medical record. I understand it is my right
as the patient, parent or legal guardian, to obtain a copy of my or my child’s medical record, including the record
of the Telehealth services.
4. I understand that the benefit of receiving Telehealth services include a more efficient medical treatment and
management, and obtaining a health care provider’s expertise even when he or she is not in the same room
(therefore saving travel time and expense for all).
5. I understand that potential risks with the use of Telehealth technology include interruptions, insufficient
information submission, low-resolution images, delays in treatment due to equipment deficiencies, unauthorized
access to transmitted data by unauthorized third parties, and technical difficulties. SHC has taken steps to
address these potential risks to reduce the likelihood of occurrence, and staff is available to address technical
issues that occur during the delivery of any Telehealth services.
6. In case of a medical emergency or adverse reaction to treatment during Telehealth services provided at an
offsite clinic, the patient presenter (who will be there in person at the same site as the patient) will follow that
site’s protocol for such medical emergencies. In case of a medical emergency or adverse reaction to treatment during
Telehealth services provided directly through the SHC patient portal or other electronic means, the patient or his or
her parent or guardian shall call 911 to receive emergency care.
7. If video functionality is lost or distorted during Telehealth services in such a manner to make transmission
inadequate, then the Telehealth services shall be terminated and rescheduled. If audio functionality is
lost during a video Telehealth visit, the session may be continued through the use of a telephone.
Informed Consent for Telehealth Services
Shriners Hospitals for Children®
*Except Texas
Patient Information Label
*TIC1*
Form #TIC1
05/2020
Page 1 of 2
Informed Consent for Telehealth Services
8. Details of the patient’s healthcare information may be discussed with those medical a n d a d m i n i s t r a t i v e
personnel at an offsite Telehealth clinic who require such information for treatment, scheduling or billing
purposes.
9. Non-medical, non-SHC technical personnel may be present during the Telehealth services to assist with
video transmission and equipment. Additional medical personnel may be present during the Telehealth
services as observers. All of these individuals are required to maintain confidentiality of the patient’s healthcare
information. I will be informed of their presence during or prior to the Telehealth services and will have the right
to request: (1) the omission of specific details of my or my child’s healthcare information that are personally
sensitive; (2) that all personnel leave the Telehealth services area; and (3) that the Telehealth services be
suspended or terminated at any time.
10. I may withhold or withdraw consent to Telehealth services at any time without risking the right to future care
or treatment or any benefits available to me or my child, and I understand that an alternate in-person
appointment may be scheduled at my request.
11. I understand what the Telehealth services involve, as well as alternatives to the Telehealth services. I also
understand that I have the opportunity to ask questions and receive additional information, and I will not
proceed with the Telehealth services unless all of my questions and concerns are answered to my
satisfaction.
12. This document will remain in effect for subsequent Telehealth services provided by SHC until revoked in
writing by the undersigned, or upon the patient's 18th birthday, at which time a new form will need to be
completed. If signed by a parent or guardian, I/we certify that I am/we are the natural or adoptive parents
or legal guardian of the patient named above, and that I am/we are legally authorized to consent to the
medical care of the patient. I/we agree to notify SHC if there is any future change in this relationship, and
to provide documentation to confirm such relationship, if requested.
By signing this form, I certify that:
• I have read or had this form read and/or had this form explained to me.
• I fully understand its contents, including the risks and benefits of Telehealth services offered to me
or my child, and
• I will not proceed with the Telehealth services unless all of my questions or concerns are answered
to my satisfaction.
Signature of Patient/Parent/Legal Guardian
Date/Time
Print Name and Relationship to Patient
Signature of Patient/Parent/Legal Guardian
Date/Time
Print Name and Relationship to Patient
Informed Consent for Telehealth Services
Shriners Hospitals for Children®
*Except Texas
Form #TIC1
Patient Information Label
05/2020
Page 2 of 2
Medical History Questionnaire
Cuestionario de historia clínica
Patient Name/ Nombre del paciente:________________________________________
Patient Date of Birth/ Fecha de nacimiento del paciente: ________________________
BIRTH HISTORY / HISTORIAL MÉDICO DESDE EL NACIMIENTO
 Yes
Sí
Did the child’s mother receive pre-natal care during the pregnancy?
Durante el embarazo ¿recibió la madre cuidados prenatales?
Birth weight:
Peso al nacer:
Pounds:
Libras:
 No
No
Ounces:
Onzas:
Was child born on due date?
¿Nació en la fecha esperada?
 On
 Justo en la fecha
 After
 Después
Type of delivery:
El parto fue:
 Vaginal
 Natural (vaginal)
 Cesarean section; why?
 Cesárea ¿Por qué?
Was the baby born breech?
¿El niño nació de nalgas?
 Yes
Sí
 No
No
 Before, how many weeks?
 Antes ¿cuántas semanas?
 Unknown
Desconhecido
Did the mother take any medications during the pregnancy?
 No  Yes; what type?
 No
 Sí ¿de qué tipo?
Durante el embarazo ¿tomó la madre medicamentos?
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Were there any problems during pregnancy?
 No  Yes - explain:
Durante el embarazo ¿hubo complicaciones?
 No
 Sí – Explique
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Were there any problems with the delivery?
 No  Yes -explain:
Durante el parto ¿hubo complicaciones?
 No
 Sí –
Explique___________________________________________________________________________________________
Was the child in NICU?
¿Estuvo el niño en la UCIN (Cuidados Intensivos Neonatales)?
 No  Yes, how long?
 No
 Sí – ¿Cuántos días?
FAMILY MEDICAL HISTORY / HISTORIAL MÉDICO FAMILIAR
Do any members of your child’s immediate family have any health problems, birth defects, or allergic reactions to anesthesia?
(Parents, grandparents, brothers, sisters, which are blood relatives)
¿Algún miembro de la familia directa de su hijo padece de algún problema de salud, malformación congénita, o ha sufrido una
reacción alérgica a la anestesia? (padres, abuelos, y hermanos/hermanas consanguíneos)
 No  Yes: if yes please list:
 No  Sí – Si la respuesta es “sí”, por favor diga cuáles:
 Orthopedic /  Ortopédico
 Syndrome /  Síndrome
 Neurologic problems /  Trastornos neurológicos
 Heart problem /  Cardiopatías
 Malignant hyperthermia /  Hipertermia maligna
 Other / Otro
 Cancer /  Cáncer
1
Patient Name/ Nombre del paciente:________________________________________
Patient Date of Birth/ Fecha de nacimiento del paciente: ________________________
MEDICAL/SURGICAL HISTORY / HISTORIAL MÉDICO/QUIRÚRJICO
Has your child currently or ever had any of the following conditions? (Check all that apply)
Su hijo ¿padece o ha padecido de cualquiera de las siguientes afecciones? (Marque las casillas correspondientes)
 Abnormal bleeding/bruises
 Hemorragias / Hematomas (moretones)
 Heart problems
 Cardiopatías
 Shunt/ Brain Fluid
 Shunt (desviación)
 Asthma/breathing problems
 Asma /Trastornos respiratorios
 Thyroid problems
 Trastornos de la tiroides
 Seizures
 Convulsiones
 Broken bones
 Huesos fracturados
 Swollen joints
 Inflamación de articulaciones
 Arthritis
 Artritis
 Bone/joint infection
 Infecciones de huesos/articulaciones
 Numbness or tingling
 Entumecimiento o cosquilleos
 Diabetes
Diabetes
 Urinary tract infection
 Infecciones de la vía urinaria
 Trouble controlling bladder
 Incontinencia de orina
 Kidney problems
 Trastornos renales
 GI problems/constipation
 Trastornos gastrointestinales /Estreñimiento
 Trouble controlling bowels
 Incontinencia fecal
 Trouble feeding
 Trastornos alimenticios
 Unexplained weight change/ weight loss
 Cambio inesperado de peso corporal/ pérdida de peso
 Moles/birthmarks
 Lunares/manchas de nacimiento
 Weight gain (excessive)
 Subida (excesiva) de peso corporal
 Skin rashes
 Erupciones cutáneas
 Trouble swallowing
 trastornos de la deglución
 Wounds
 Heridas
 Trouble seeing
 Problemas de visión
 Trouble hearing
 Deficiencia auditiva
 Ear infections
 Infecciones de oídos
 ADD/ADHD
 Déficit de atención con o sin Hiperactividad
 Balance problems
 Trastornos del equilibrio
 Delayed development
 Retraso del desarrollo
 Anxiety/Depression
 Ansiedad/Depresión
 Suicide attempt
 Intento de suicidio
 Cancer
 Cáncer
List any previous surgeries, hospitalizations, and /or studies:
Anote todas las cirugías y/o estudios que le hayan realizado:
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If your child had surgery, were there any problems with the anesthesia?  No  Yes: Describe:
Si alguna vez han operado a su hijo ¿tuvo complicaciones con la anestesia? No  Sí – Explique:
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Has your child ever had a blood transfusion?
 No  Yes: Why?
Su hijo ¿ha recibido alguna vez una transfusión sanguínea?
No  Sí - ¿Por qué?
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MEDICATIONS / MEDICAMENTOS
Please list all the medicines, vitamins, herbs, and supplements that your child takes regularly
Por favor, anote todos los medicamentos, suplementos, y remedios caseros(hierbas) que tome su hijo
Name of medicine
How much is given
Reason for taking
Nombre del medicamento
Dosis
Motivo
2
Patient Name/ Nombre del paciente: ________________________________________
Patient Date of Birth/ Fecha de nacimiento del paciente: ________________________
GROWTH AND DEVELOPMENT/FUNCTIONAL HISTORY
CRECIMIENTO Y DESARROLLO/ HISTORIAL DE MOTRICIDAD
Walked with help:
Empezó a andar con ayuda:
Age your child first: Sat alone:
A qué edad: Se sentó a solas:
Walked independently
Empezó a andar a solas:
Eat independently
Comer a andar a solas:
Does your child use any of the following?
Su hijo ¿utiliza alguno de los siguientes artículos?
 Braces
 Ortesis
 Splints
 Férulas
 Crutches
 Muletas
 Walker
 Andador
 Shoe inserts/lift
 Plantillas para zapatos/Alzas
 Wheelchair
 Silla de ruedas
 Prosthesis
 Talking device
 Cane
 Prótesis
 Bastón
 Dispositivo de generación del habla
Does your child receive any of the following therapies, and if so, how often?
Su hijo ¿recibe alguna de las siguientes terapias?
 Physical
 Occupational
 Speech
 Física
 Ocupacional
 Del habla
These activities can be done independently by my child: (check all that apply)
Mi hijo puede realizar a solas las siguientes actividades: (marque todas las casillas correspondientes)
 Walking
 Sitting
 Toileting
 Andar
 Sentarse
 Usar el servicio/baño
 Feeding
 Dressing
 Hygiene needs
 Alimentarse
 Vestirse
 Asearse
First menstrual period:
Primera menstruación:
Grade in school:
Curso/grado:
 N/A Date:
N/A Fecha:
Age:
Edad:
N/A (too young)
N/A (aún es muy pequeño)
Special education
Educación especial
 No  Yes
No  Sí
Does your child attend school regularly  Yes  No
Su hijo ¿va a la escuela con regularidad?
School concerns:
Preocupaciones escolares:
ALLERGIES/ ALERGIAS
Allergies  No  Yes: if yes, please describe the type of reaction that happens
Alergias  No  Sí - Si la respuesta es sí, describa la reacción:
Allergy / Alergia
Reaction / Reacción
Food allergies:
Alergias alimenticias
 Yes  No
 Sí  No
Environmental allergies:  Yes  No
Alergias ambientales:
 Sí  No
Latex allergy:
Alergia al látex:
 Yes  No
 Sí  No
Latex precautions:
Precauciones con látex:
 Yes  No
 Sí  No
Name of person completing form: _______________________________________ Date: _______________________
Signature:_____________________________________ Relationship to patient:____________________________
3
CERTIFICATION OF INTERNATIONAL
HEALTHCARE PROFESSIONAL
Patient Name/ Nombre del paciente: __________________________________________
Patient Date of Birth/ Fecha de nacimiento del paciente: ______________________
I have reviewed the attached Request for Care form for and certify that the following requirements
have been met:
1. I have completed/ reviewed the PreviousTreatment/Treatment Provided sections of the
application.
2. The child will be under 18 years of age on their first visit date at Shriners Hospitals.
3. The medical problem is within the scope of care of Shriners Hospitals (Burn/ Plastics/
Orthopedic/Cleft Lip & Palate/ Spinal Cord Injury).
4. I can be reached at the address and phone number listed on the Request for Treatment form
in order to maintain continuity of care.
5. The patient does not have chronic conditions outside of SHC scope of care or services
provided by the hospital that would necessitate continuum of treatment outside of SHC.
6. Record of up-to-date immunizations is included below.
7. Pertinent medical records and/or x-rays are included with the application.
Immunization/Vaccines
Tuberculin skin test or recent chest x-ray
Chicken Pox vaccine or history of chicken pox
DPT/Hep B/ Hib
Measles , Mumps, Rubella
COVID-19
Date received
Additional Comments or Health Information:
_____________________________________________________________________________________________
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Healthcare Professional Signature: __________________________________ Date:_____________________