Domestic Medical Inquiry Form

If you are interested in learning more about our services or have a question about your child’s health, please complete the form below. Our team will be happy to connect you with a Nationwide Children's expert to get you the information you need.

Please note: If you are not the parent or legal guardian of the child for which you're inquiring, we will need a signed consent form prior to communicating about the child.

If you have difficulty completing this form, please contact us at GlobalPatientServices@NationwideChildrens.org

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Patient Information

Patient First Name ^* Please enter First Name

Patient Last Name ^* Please enter Last Name

Patient Date of Birth ^*

Enter a valid Year

Patient Gender ^*

Please select a gender

Address Line 1 ^* Please enter Address Line 1

Address Line 2

City ^* Please enter a City

State ^*

Please select a State

ZIP Code ^* Please enter your ZIPcode

Country ^*

Please enter a Country

Primary Diagnosis Conditions ^* Please enter one or more Condition (Maximum characters: 4000) You have {{pc.maxConditionLength - pc.Condition.length}} characters left.

Patient's Spoken Language ^*

Please select a language

If other ^* Please enter other language spoken

Parent/Guardian Information

Guardian ^*

Please select a Guardian Type

Guardian - Other ^* Please enter another Guardian Type

Parent/Guardian First Name ^* Please enter a First Name

Parent/Guardian Last Name ^* Please enter a Last Name

Parent/Guardian Date of Birth ^*

Please enter a valid Date of Birth

Your Email Address ^* Enter a valid email address in name@email.com format Please enter an Email Address

Confirm Email Address ^* Enter a valid email address in name@email.com format Please enter an Email Address Email addresses do not match

Country Code ^* Please enter a Phone Number Country Code

Phone ^* Please enter a Phone Number

Phone Type ^*

Please enter a Phone Number

Country Code

Alternative Phone

Alternative Phone Type

Address Line 1 ^* Please enter an Address

Address Line 2

City ^* Please enter a City

State ^*

Please select a State from the provided list

ZIP Code ^* Please enter a valid ZIPcode

Country ^*

Please enter a Country

Payment & Physician Information

Payment Source ^*

Please choose a Payment Source from those listed

Other Payment Source ^* Please enter another Payment Source

Primary/Referring Physician First Name ^* Please enter First Name

Primary/Referring Physician Last Name ^* Please enter Last Name

Primary/Referring Physician Email Address The email address provided is invalid

Country Code ^* Please provide physician's phone number country code

Primary/Referring Physician Phone Number ^* Please provide physician's phone number

Do you have an electronic copy of the patient's medical records (in English)? ^*

Yes

Please indicate whether or not you have an electronic copy of the patient's medical records

How did you hear about Nationwide Children's Hospital?

Have you already been communicating with a Nationwide Children’s staff member ? ^*

Yes

Please indicate whether or not you have been communicating with a Nationwide Children’s staff member

Please provide the full name of the staff member. ^* Please enter full name of the staff member.

Tell us about your question ^* Please enter a question before continuing

Thank you for your medical inquiry

Thank you for contacting Nationwide Children's Hospital. We will reply to your message within 3 business days.

We are sorry, it appears that your request did not go through. Please call the Welcome Center at 800-863-0469 during the following hours 8:00 a.m. to 5:00 p.m.

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Domestic Medical Inquiry Form

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Patient Information

Parent/Guardian Information

Payment & Physician Information

Thank you for your medical inquiry