Patient Evaluation Form

Thank you for your inquiry about our Pediatric Hand Transplantation Program. Please review the Patient Selection Criteria before submitting the following information so we may begin to evaluate you or your child.

Patient Information

Patient's Name *

Date of Birth *

Gender *

Race

Ethnicity

City, State and Country of Residence *

Patient / Guardian Contact Information

Name *

Relation to Patient *

Phone *

Email *

Patient Description

Please provide a description of your child (or yourself, if applicable).

Date of Incident *

Nature of Incident *

Date of Amputation *

Treatment To-Date *

Prosthetics Used (If Applicable)

Other Medical Problems (If Applicable)

Chronic Medications (If Applicable)

Physician / Provider Information

Please provide information of the physician or provider who will provide a referral for hand transplantation and a clinical summary.

Name of Provider *

Provider Practice *

Address *

Phone *

Email *

Photos

Please provide photos of the upper extremities and x-rays, if you have them.

Upload photos

Files must be less than 2 MB.
Allowed file types: gif jpg png bmp eps tif pict psd txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml zip.

Upload photos

Files must be less than 2 MB.
Allowed file types: gif jpg png bmp eps tif pict psd txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml zip.

Upload photos

Files must be less than 2 MB.
Allowed file types: gif jpg png bmp eps tif pict psd txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml zip.

Upload photos

Files must be less than 2 MB.
Allowed file types: gif jpg png bmp eps tif pict psd txt rtf html pdf doc docx odt ppt pptx odp xls xlsx ods xml zip.

Once we receive your information and review it, we will be contacting you.

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