The Global Patient Services Program at Children's Hospital of Philadelphia (CHOP) has expertise in handling referrals and transferring cases from physicians around the world. To refer a patient, you can:

• Fill out the Referral Form below with as much information as possible.
• Call us at 001-267-426-6298 (Business hours are from 8:30 a.m. – 5 p.m. North American Eastern Standard Time)
• In all cases, a bi-lingual representative from the IPS program will contact you within 24 hours to discuss your patient.

This form is not to be used in the case of an emergency. If this is a medical emergency, please call 911 or your local emergency access provider.

The form below is intended for international referrals. If you are looking to refer a patient who resides within the United States, use our National Patient Services form. 

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?

--None--CHOP PhysicianConference/EventEmbassyEmployerFamily or FriendInsuranceInternetMy PhysicianNews/Media/TV

Other 

*Country Name

--None--AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBudapestBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChannel IslandsChileChinaChristmas IslandCocos(Keeling) IslandsColombiaComorosCongoCongo, The Democratic RepublicCook IslandsCosta RicaCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaEuropean Money UnionFalkland Islands(Malvinas)Faroe IslandsFijiFinlandFranceFrance, MetropolitanFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuineaGuinea-bissauGuyanaHaitiHeard and McDonald IslandsHoly See/Vatican CityHondurasHong KongHungaryIcelandIndiaIndonesiaIran (Islamic Republic of)IraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKoreaKorea, Democratic People's RepublicKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritiusMayotteMexicoMicronesiaMoldovaMoldova, Republic ofMonacoMongoliaMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorwayOmanPakistanPalauPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarReunionRomaniaRussian FederationRwandaSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbia and MontenegroSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia/South SandwichSpainSri LankaSt. HelenaSt. Pierre and MiquelonSudanSurinameSvalbard and Jan Mayen IslandsSwazilandSwedenSwitzerlandSyrian Arab RepublicTaiwanTajikistanTanzania, United Republic ofThailandTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUruguayUS Minor Outlying IslandsUSAUzbekistanVanuatuVenezuelaVietnamVirgin Islands (US)Virgin Islands, BritishWallis and Futuna IslandsWestern SaharaYemenZambiaZimbabwe

Best time to contact you by phone?

--None--MorningAfternoonEvening

Appointment Information*Reason for Appointment

--None--ConsultationEvaluationFollow-upNew Patient VisitReferralOther

*Diagnosis:

--None--ArthritisAsthmaAtrial Septal DefectAutismBiliary DiseaseBlount's DiseaseBone Marrow TransplantBurnCardiomyopathyCerebral InfarctCerebral PalsyChronic Lung DiseaseCongenital Cardiac AnomalyCongenital Cystic Adenomatoid MalformationCongenital SyndromeCraniofacial AbnormalityCystic FibrosisDermatitisDiabetesEncephalitisEndocrine DisorderEosinophilic EsophagitisGastroenterisitisGastroesophageal RefluxGastro-Intestinal AbnormalityHyperinsulinismImmunodeficiencyInflammatory Bowel DiseaseKidney DiseaseLeukemiaLiver FailureMeningo-MyeloceleMetabolic DisorderNeuro/Developmental DisorderNeuroblastomaNeurofibromatosisOphthalmic AbnormalityOrthopedic AbnormalityPeriodic Fever SyndromePrecocious PubertyPulmonary AbnormalityPulmonary HypertensionRenal StonesRetinitis PigmentosaScoliosisSeizure DisorderSickle Cell AnemiaSinusitisTumorTwin To Twin Transfusion SyndromeUpper Respiratory InfectionUrogenital AbnormalityOther

Additional Information: