F A C I N G   T H E   W O R L D
REFERRAL FORM

Please note: Facing the World seeks to provide help ONLY for children with facial deformity whose family are unable to access the required corrective surgery by any other means [be it for financial reasons or lack of existing resources in the country of referral]

 

This form will help us at Facing The World to evaluate the child’s condition and whether we will be able to help. It is important that as much information as possible is provided.

The second part will need to be completed by a Doctor.
Patient’s Name * :
Likes to be called :
Age :
Male/ Female : Male    Female
Address for all correspondence :
Languages spoken :
Religion :
Next of Kin :
Contact Telephone/e-mail :
Occupation of Parents/Guardian :
How is your child affected by their facial defect? :
How did you become aware of ‘Facing The World’? :
Medical details: (to be completed by a doctor)

In order to make an assessment of the suitability of each child for surgery, we would ask you to complete this form with as much detail as possible. It is important that we obtain all relevant information on the medical and social aspects of the case.
Presenting complaint (the reason the child is being referred to Facing the World, please include details of diagnosis, history and any previous treatment for the condition) :
Immunisations (with dates) :
Past medical history (with dates, please include any history of parasite infestation and treatment) :
Past surgical history :
Medicines (any treatments currently being taken by the child) :
Allergies :
Physical Disabilities :
Mental state (How does the child compare to other children of their age in terms of verbal and non verbal communication, reasoning and emotional development. Please state the estimated mental age of the child.) :
Social skills (Describe much interaction does the child show compared to other children of their age e.g. How does the child interact with those around them, family, friends, strangers?) :
Special needs (Any needs the child may have that have not been stated so far) :
Ability to travel (Do you see any difficulties that this child might have if travelling to Europe) :
Aftercare (Please state who will be involved in maintaining patient contact when the child returns home) :
Special needs (Any needs the child may have that have not been stated so far) :

Medical reports:

In order to make our full assessment of the child please send as much of the following information as possible.
  • Medical/ Paediatric report from the local hospital
  • Clinical photographs of the child, with several different views
  • Immunisation status with certificate
  • Chest X ray
  • Any other information you feel would be useful

Contact details: (Please include email, Fax and Phone numbers if available)
Contact details of Doctor completing this form (Please state your medical speciality i.e. Family Doctor, Paediatrician etc) :
Contact details and medical speciality of doctor responsible for aftercare of child’s condition in home country :

Thank you for completing this form. If we are able to help we shall contact you once the application has been reviewed by the medical committee.