Refer a Child
Need help finding heart care for a child?
Share a brief, non-sensitive description of the support you are seeking. Our team will respond and explain the proposed referral process — from specialist review in India to travel and follow-up.
Urgent symptoms? Seek immediate care through local emergency services or a qualified healthcare facility. This website is not an emergency service.
Patient forms
Official forms to get started
Download and complete the official TICHFA forms below. Keep them ready — our team will tell you exactly when and where to submit them. Never send medical records through this website form. When your team requests documents, upload them through the Secure Patient Portal — encrypted, receipt-confirmed, and visible only to authorized staff.
Child Patient Registration Application
The official starting form — register a child for TICHFA support.
Expanded Patient Registration Form
The expanded registration form with fuller medical and guardian details.
Guardian Consent Form
Required consent from the child's parent or guardian — printable PDF or editable Word file.
Medical Information Release Authorization
Authorizes hospitals and clinics to disclose the selected medical information to TICHFA or a treating hospital.
Fomu kwa Kiswahili
Official forms in Swahili
The child registration application and the guardian consent form are also available in Swahili for families in Uganda and East Africa.
Usajili wa Mtoto — Child Registration (Swahili)
Fomu rasmi ya usajili wa mtoto kwa msaada wa TICHFA.
Ridhaa ya Huduma — Guardian Consent (Swahili)
Fomu ya ridhaa ya mzazi / mlezi kabla ya usindikaji wa taarifa.
Formulaires en français
Les mêmes formulaires en français
Les trois formulaires officiels sont disponibles en français, avec les mêmes choix de consentement, protections de la vie privée, champs de signature, informations de passeport, contacts d'urgence et sections d'antécédents médicaux. Avant toute utilisation avec des familles, ces traductions doivent être vérifiées par un réviseur juridique / médical francophone qualifié — les documents portent cette mention.
Demande d'inscription et de soutien pour enfants
Version française du formulaire d'inscription officiel.
Demande internationale détaillée
Version française du formulaire détaillé (passeport, visa, antécédents médicaux).
Consentement du tuteur et autorisation médiatique
Version française du formulaire de consentement OUI / NON.
What happens next
- 01
We acknowledge
Our team confirms receipt of your inquiry and explains the proposed process.
- 02
Consent and records
With your consent, we help compile records — echocardiograms, ECG, labs, history — through a secure intake process.
- 03
Specialist review
A qualified pediatric cardiac team reviews the case. TICHFA never diagnoses or promises surgery is appropriate.
- 04
Care and cost plan
The hospital shares its treatment recommendation and estimated costs.
- 05
Funding, visa and travel
We explore funding, guide visa documentation and coordinate travel — then support recovery, return and follow-up.
Records we help families compile
- Echocardiogram reports
- ECG
- CT / MRI reports when available
- Previous surgical records
- Laboratory results
- Physician referral
- Passport information
- Child's medical history
Collected only through a secure, consent-based intake process — never through general forms.
Before contacting us
- Prepare a brief non-medical description of the support you are seeking.
- Have your country and preferred contact method ready.
- Detailed records should be shared only after a secure, consent-based intake process is established.