REPORT A SURGERY Use this form to report a previously unreported surgery. 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 CodePlease enter your child's FIRST and LAST name:*Child's Birth Date: format as YYYY-MM-DDChild's Death Date, if applicable: format as YYYY-MM-DD 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 (YYYY-MM-DD)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. Managing Your Child's Care Surgeries & Growth Charts Resources Blog Publications Stories News Events Stay updated on SOFT Email* Consent* I agree to receive communication from SOFT. Don't worry, we don't spam.*NameThis field is for validation purposes and should be left unchanged.