Tell Us Your Story!

Patient Information

Child's Name  *Child's Age  *Child's Birth Date  *Diagnosis  *

Contact Information

Parent's Name(s)  *Sibling's Name(s) Mailing Address  *Daytime Phone Number  *Email Address(es)  *

About the Patient

Favorite Color Favorite TV Show Favorite Food Favorite Sport Favorite Person Favorite Singer Any Other Fun Fact 

Tell us about your Child

What was your child's life like before coming to Children's Hospital of Georgia? What brought you to Children's Hospital of Georgia? What is your child's diagnosis, and what care has he or she received for their diagnosis?  *Out of this unforeseen circumstance, what has the most positive outcome been thus far? Describe to us your child's best day since his or her diagnosis. Are there any physicians or staff members that hold a special place in your heart, and if so, why? Was there anything you would like to share that we did not already ask?