Treatment Enquiry Form

Please complete this form for our international treatment enquiry:

Patient Data

Mr./Ms.

Title

First name

Last name

Date of Birth (DD/MM/YYYY)

Address

Zip Code and City

Country

Phone

Fax

E-Mail

Medical Information

Disease(s)/Sympom(s) to be treated

What do you expect from your appointment/treatment (specific indication/desired treatment)?

Select specialty department (if known)

Further relevant diagnoses

Additional information (e.g. contact data of treating physician in the country of residence)

Desired appointment date/s

Medical Records

Once we have evaluated your data, we will send you a link where you can upload you medical records and further data we might ask for. The information in this form as well as the uploaded data is encrypted and no unauthorised person outside our hospital will be able to access this information.