Medical Advice Request Form

medtourism24

International Patient Admission Form

Please note the following points before completing the form:
1- The format of all attachments is: jpg, gif, pdf, png
2- All related documents (tests, etc.) in a zip file (zip, rar) and then send

"*" indicates required fields

Patient name*

Patient surname*

Passport number

Date of birth*

Gender*

Female

Male

Marital status

Single

Married

Phone number*

Residence address

Address City Country

Early diagnosis of the disease*

Description of the disease*

Selected hospital

Selected doctor

Services required*

Service level*

Send the documents of your illness to the attachment

If you have more than one document in each case, zip them all (zip, rar) and then send them.

Experiments

Drop files here or

Max. file size: 160 MB.

Radiography

Max. file size: 160 MB.

Sonography

Max. file size: 160 MB.

CT Scan

Max. file size: 160 MB.

MRI

Max. file size: 160 MB.

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