chILD Physician Directory Submission Form

chILD Physician Directory Submission Form

Please complete all required sections to submit your hospital's or clinic's information for the directory. Once submitted, we will contact you within a few working days to confirm the listing.
Basic Center Information
Institution Name
Center Type
Primary Contact Name
Primary Contact Email
example@example.com
Primary Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Mailing Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Country
Which specialists are part of your chILD care team? (Check all that apply)
Is your institution a lung transplant center?
Main Clinic Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Clinic Website URL
Team Lead / Director

(not published- to be used by the chILD Foundation)
Name

First NameMiddle NameLast Name
Email for Foundation use only
example@example.com
Is your institution an active member of the chILD Research Network (chILDRN)?
Is your institution actively entering data into the chILD Registry Collaborative?
If you are not in the US, are you a member of a chILD Research Network? If so, which one?
Referrals and Access
Do you accept out-of-state referrals?
Is telehealth available?
Do you have a transition to adult care program?
Approximate number of chILD patients seen annually
Public Listing
Information to publish
Additional information for public listing
Submission Agreement
Confirmation of Accuracy and Publication Authorization
Full Name of Person Submitting

First NameLast Name
Title / Role
Date

MonthDayYear
Date
Should be Empty:

chILD Physician Directory Submission Form

Basic Center Information

Team Lead / Director

Referrals and Access

Public Listing

Submission Agreement