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International patient information

International patient information

Families seeking care for children who are outside the United States should complete the following application form and include all necessary documents, which are listed below.

All medical documents submitted should be the original document from your child’s physician, and must include an English translated copy.

Families may choose to contact the new patient intake coordinator prior to completing their request for treatment to inquire if their child has a condition that the Chicago Shriners Hospital would be able to provide treatment for. You can contact the new patient intake coordinators at 773-385-KIDS (5437).

International Patient Request for Treatment Application

Documents required:

  • A complete copy of the child’s immunization record, including measles, mumps, and rubella vaccine, varicella and pertussis
  • A copy of the child’s birth certificate and a copy translated into English
  • A letter in English from your doctor stating that the child is free from contagious disease, especially addressing hepatitis, tuberculosis, MRSA or any parasitic diseases
  • X-ray films and medical records from your child’s physician pertaining to his/her condition that you are seeking treatment for at Shriners Hospitals for Children — Chicago
  • The Chicago Shriners Hospital does not provide transportation, housing, or a translator. Therefore, it is necessary for you to have an affidavit completed by the person that you will be staying with while in the United States.

Please send completed forms to:

Shriners Hospitals for Children — Chicago
New Patient Intake Department
2211 N. Oak Park Ave.
Chicago, IL 60707