Request for treatment SJD Barcelona Children's Hospital

Request for treatment

Please complete this form to request an appointment or information about child and maternal treatment options at SJD Barcelona Children's Hospital. We will review your request and answer you as soon as possible.

Fields with * are mandatory

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Details of the contact person

First name and last name *

Email *

Prefix

Telephone number *

Patient details

First name *

Last name *

Date of birth *

Day

Month

Year

Country of residence *

Language *

Please tick the language in which you would like us to contact you.

What do you hope to obtain from our centre?

Please tick one or more options *

To confirm a diagnosis (second opinion).

To find out about alternative treatments.

Medical consultation in person.

Online medical consultation.

To receive treatment.

Pregnancy and childbirth care.

Other.

Please state other reasons.

Patient medical information

Diagnosis or symptoms *

Specialist medical areas

Specialist medical areas which have assessed the case previously. Example: Oncology

Medical report and results of additional tests and images (X-rays, scanners, etc.)

Please attach the report in English, Spanish, Russian, French or Catalan.
Important: please attach a medical report and results of recent tests so that our specialists can assess the case properly and as quickly as possible.

medical file

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Files must be less than 10 MB.
Allowed file types: gif jpg jpeg png txt pdf doc ppt pptx.

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I do not have a medical report or additional test results for the patient.

I have read and accept the legal notice and the terms of use *

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Request for treatment

SJD Barcelona Children's Hospital is a non-profit organization