Application form
Your application in 3 easy steps:

Step 1: Name and address

Patient

Salutation *
 
Name*
 
First name*
 
Date of birth*
 
Nationality*
 
Denomination
Street number
  HouseNumber
Postal Code*
 
Place of residence *
 
Country*
 
Phone
Mobile*
 
Email*
   
Accompaniment

Salutation *
 
Name*
 
FirstName*
 
DateOfBirth*
 
Nationality*
 
Denomination
StreetNumber
    HouseNumber
Postal Code*
 
Place of residence *
 
Country*
 
Phone
Mobile*
 
Email*
   
Upload copy of passport


Step2: Disease Description

Description of your condition *
 
Treatment Expected
Requirement documents-Health Records
If possible upload your documents such as medical history , radiographs / CT / MRI images , lab values, etc. high here:


Step3: Desires Additional Services

Patient

Accompaniment
Airport pick up and transfer
Limousine Service
Not Ambulance
Car Rental
Car rental with driver
Translation services
Interpreting services
DoctorTalks
PrivateEscort
Translation doctor's letter and discharge papers
Prefabrication of documents
Accomdation
Shared rooms hospital
Single hospital
Simple hotel / guesthouse
Hotel 3 Star
Apartments4 Star
Hotel 5 Star
Apartment

Services for escort

Accompaniment
Vechile Monitoring
Airport pick up and transfer
Limousine Service
Not Ambulance
Car Rental
Car rental with driver
Translation services
Interpreting services
DoctorTalks
PermanentMonitoring
Monitoring on an hourly basis
Translation doctor's letter and the discharge papers
Prefabrication of documents
Accomdation
Simple hotel / guesthouse
Hotel 3 Star
Hotel 4 Stars
Hotel 5 Star
Apartments