医护专业人员: 如何将患者转介至CHOP CHOP的国际患者服务部具有处理世界各地的医生转介来的患者的专业知识和技能。如要转介一名患者,您可以: 尽量详细地填写以下的转介表。本表格须用英文填写,以便我们的国际服务协调员能评估您提交的信息。 拨打我们的电话001-267-426-6298 (工作时间为北美东部标准时间上午8:30至下午5点) 在任何情况下,IPS项目的双语代表都会在24小时内与您联系,讨论您的患者的问题。 在患者需要急救的情况下不宜使用本表格。如果这是属于紧急情况,请拨打911或致电给您当地的急救服务提供机构。 Patient Information*First Name *Last Name *Patient Date of Birth: (mm/dd/yyyy) Referrer Information*Physician First Name *Physician Last Name: *Phone *Email *Requestor Email: *How did you hear about us? CHOP PhysicianConference/EventEmbassyEmployerFamily or FriendInsuranceInternetMy PhysicianNews/Media/TV Other *Country Name AfghanistanAland IslandsAlbaniaAlgeriaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBolivia, Plurinational State ofBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCongo, the Democratic Republic of theCook IslandsCosta RicaCote d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly See (Vatican City State)HondurasHungaryIcelandIndiaIndonesiaIran, Islamic Republic ofIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedonia, the former Yugoslav Republic ofMadagascarMalawiMalaysiaMaldivesMaliMaltaMartiniqueMauritaniaMauritiusMayotteMexicoMoldova, Republic ofMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorwayOmanPakistanPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalQatarReunionRomaniaRussian FederationRwandaSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuela, Bolivarian Republic ofViet NamVirgin Islands, BritishWallis and FutunaWestern SaharaYemenZambiaZimbabwe Best time to contact you by phone? MorningAfternoonEvening Appointment Information*Reason for Appointment ConsultationEvaluationFollow-upNew Patient VisitReferralOther *Diagnosis: 2 Stage Hypospadias Repair Surgery22q WorkupAlagille SyndromeAllergic DisorderAllergy ConsultationAlopeciaAmplified Musculoskeletal Pain ClinicAmplified Pain ConsultAMPS EvaluationAnemiaAnnual Evaluation with Neuro-OncologyAnnual Outpatient Follow-up VisitApneaArrhythmiaArterio-venous MalformationArthritisAsthmaAtaxia/Intermittent Ataxia PanelAtrial Septal DefectAttention Deficit Hyperactivity DisorderAudiology ConsultationAutismAutoimmune DisorderBack PainBehavior Health Follow-upBilateral Ear Reconstruction with Rib AutograftBiliary DiseaseBlindnessBlood WorkBlount's DiseaseBMT DonorBone CancerBone Marrow TransplantBrain DamageBrain HemorrhageBrain TumorBurnCardiomegalyCardiomyopathyCardiovascular AbnormalityCeliac DiseaseCerebral InfarctCerebral PalsyCholesteatomaChronic Lung DiseaseChylothoraxCleft LipCleft PalateClub FootConcussionCongenital Cardiac AnomalyCongenital Cystic Adenomatoid MalformationCongenital Cystic Adenomatous MalformationCongenital SyndromeConstipationCornelia De Lange SyndromeCraniofacial AbnormalityCraniosynostosisCryptorchidismCystic FibrosisDandy Walker SyndromeDeep Venous Thrombosis (DVT)DermatitisDermatologic AbnormalityDermatologic DisorderDevelopmental DelayDiabetesDiarrheaDonorEating DisorderEdemaEEGEncephalitisEncephalopathyEndocrine DisorderEosinophilic EsophagitisEpilepsyFacial DeformityFailure to ThriveFanconi SyndromeFetal AnomalyFever of Unknown OriginForeign Body in EarFractureGastro-Intestinal AbnormalityGastroenteritisGastroesophageal RefluxGastrointestinal DisorderGastroschesisGenetic DisorderGuillain Barre SyndromeGynecomastiaHand TransplantHeadacheHearing LossHeart FailureHemangiomaHematologic AbnormalityHematologic DisorderHemophiliaHepatitisHepato-splenomegalyHydrocephalusHydronephrosisHyperbilirubinemiaHyperinsulinismHypertensionIdiopathic ThrombocytopeniaImmunodeficiencyInfectious DiseaseInflammatory Bowel DiseaseIntraventricular HemorrhageKidney DiseaseLeukemiaLiver FailureLymphadenopathyLymphomaMedicationsMeningo-MyeloceleMental HealthMetabolic DisorderMuscle CancerMusculoskeletal DisorderNephrotic SyndromeNerve DamageNeuro/Developmental DisorderNeuroblastomaNeurofibromatosisNeurologic AbnormalityNeurologic DisorderNeuromuscular DisorderObesityOncologic DisorderOphthalmic AbnormalityOrthopedic AbnormalityOsteogenesis ImperfectaOsteomyeolitisOtherOtitis MediaOtolaryngology DisorderPancreatitisPeriodic Fever SyndromePharyngitisPlastic Surgical AnomalyPneumoniaPrecocious PubertyPrematurityPulmonary AbnormalityPulmonary HypertensionRenal DisorderRenal StonesRespiratory AbnormalityRespiratory DisorderRetinitis PigmentosaRetinoblastomaRetinopathy of PrematurityRheumatologic DisorderScoliosisScreeningSeizure DisorderShort StatureSickle Cell AnemiaSinusitisSpeech DisorderSpina BifidaSplenomegalyTethered CordTetralogy of FallotThalassemiaThrombocytopeniaThyroglossal Duct CystTracheo-Esophageal FistulaTraumaTrisomy 13Trisomy 21TumorTwin To Twin Transufusion SyndromeUpper Respiratory InfectionUrinary Tract InfectionUrogenital AbnormalityVascular MalformationVesicoureteral RefluxViral SyndromeWell Child CareOther Additional Information: