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Inquiry form


 
     
 

Inquiry form for patients

Please fill out the following form completely. Your information helps us to be able to work on your desires and your future stay in Germany.

You can fill out the form on-line at the computer or download the form and send it by email
at info@medical-crossborder.com or by fax at +49-231-55 63 73.

Download form:
     
Online form  
     
Protection of privacy:
Medical crossborder is very interested in the privacy and safety of our visitors. The indication of your personal data is strictly voluntary, however we need, in order to be able to answer you, at least your E-Mail address and your name. These fields are marked (*) as mandatory fields. All information registered and your personal data is strictly treated confidentially. We do not provide any information supplied to any outside organization for any reason..
Patient Information


Last name *
First name

Address
Country
Email *
Phone
Fax
Birth date
Gender   M   W
   

Medical Information
What medical service spectrum are you interested in?
Intestinal Disorders
Breast Surgery
Prostate and Bladder Disorders
 Vascular Surgery
Hip and Knee Arthroplasty Paediatrics
Oncology
 Neurosurgery
Cardiology
 Anthroposophical Medicine
Oral and Maxillofacial Surgery (OMS)
 Other services
Health check-up    
       

Medical Information

Your diagnosis / medical problem
       
Desired medical treatment
       
Do you have medical documentation and medical reports?
Which one can you send to us?
Physician´s letter
Hospital discharge letter
Surgery report
 Report course of disease
       
Diagnostic and radiologic Informations
Laboratory test
 X-ray
Cardiogram
 CT / MRT Pictures
       

Referring Physician
Please provide us with the name and contact information of your physician:
Name
Country
Phone
Fax
Email
   
If you are interested in a Health Check-up,
what kind of Health Check-up do you wish?
Full Health check-up  
Health check-up for high-risk groups:
Cardiovascular health check-up Smoker health check-up
 

Service Information
What languages do you speak?
English
 German
Chinesisch
       

Optional services

What optional services do you require?
  Stay in hospital:    
1 Bed-Room
 Treatment by Chief Physician
2 Bed-Room
    
       
How many persons do accompany you?
Number accompanying persons therefrom children
       

Do your accompanying persons need accomodation?
   
       
Is this your first treatment in one of our hospitals?
Yes No    
     
If no, in which hospitals have you been treated:
       
How did you find out about Medical crossborder?
Embassy
Relatives / friends
Referring Physician
 Insurance company
Employer
  
Internet
       
Do you have further requests, which are not included in the inquiry form,
or you would like to add any other information, please type it here:
       
 
   

 

 
 
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