Form – Add an Unreported Surgery Form - Add Unreported Surgeries Thank you for reporting an additional surgery and know that we do not share your information. This surgery information will be aggregated with that of other families, with no personal information being included and only the summary data is posted to the web site. You must be registered with SOFT, for us to add this information to the system. If you are not registered, please go to the "Register" tab of the home page's menu and register. Registration is FREE and we do not share personal information with any other organization. Please enter your FIRST and LAST name:*Please enter your contact information, used only if we have a question about the reported surgery:*Email AddressPhone Number w/Area Code Please enter your child's FIRST and LAST name:*Child's Birth Date (Month/Day/Year):Child's Death Date, if Applicable (MM/DD/YY): Click the Arrowhead to Select Your Child's Diagnosis from the Drop-down menu:*Full Trisomy 13Full Trisomy 18Mosaic Trisomy 13Mosaic Trisomy 18Other (please describe below)Describe the "Other" Affected Chromosome or Diagnosis: Below, you can enter information for as many surgeries or procedures as you want. if any were CARDIAC surgeries or procedures, please answer the special cardiac questions about them, following the surgery entries. Thanks!Click the little '+' sign at the end of the surgery row to open another blank surgery row, to enter an additional surgeryPlease enter information about the first surgery here. The fields will expand as you type in them. CLICK THE LITTLE "+" SIGN TO OPEN A NEW SURGERY ROW.*Date of Surgery (MM/DD/YY)Name of SurgeryName, City & State of HospitalName of Physician(s)Was the Surgery Successful (Yes, No, Partially) If you reported a CARDIAC surgery on this form, please complete the following:Was it difficult to find a willing cardiac surgeon (YES/NO)?Number of days in PICU after Cardiac Surgery:Was your child discharged to home (YES/NO)?If NOT still living, child's survival time after cardiac surgery: Please enter any comments here:Thank you for providing this information. Press the "Send Form to SOFT" BUTTON below to send this form.NameThis field is for validation purposes and should be left unchanged.