Enquiry form

Questionnaire for FIRST INFORMATION on PATIENT

You may also request for the French or English customized format.

Time to process your records for Treatment Plan & Quotes after receiving all medical data from patient: 3 - 5 days.

1. Last Name, First Name, (Middle initial)*

2. Gender*

3. Date of Birth*

4. Nationality, Country of residence*

5. Conversational language*

6. Complete address*

7. E-mail

8. Phone*

9. Fax

11. About your medical condition: Your Prognoses / Diagnosis or clinical and physical condition*

Important:
a.  Every person traveling with patient must bear a valid passport for 6 [six] months from the planned date of travel.
b.  Certain procedures need photos to make a fair assessment for a quote, total period of stay etc.
c.  Some countries , may require a visa subject to passport holder's nationality.
d.  Period of total stay for Renal Tx = 3 weeks, any other Tx = 6 - 8 weeks.

DISCLAIMER

• Prices will be for rough planning purposes only to assist the patient in understanding the possible range of costs.  The cost ranges provided are based upon our best understanding of the patient's condition at the time of contact and do not represent a minimum or maximum potential cost.
• Actual estimates for procedure, recovery as in-patient and out-patient which includes accommodation in an European style facility, cannot be accurately provided until the patient expresses the need for additional services, and the physician-designate releases the final report to qualify patient for requested treatment.