(Please replace the descriptions in the fields with your text)

Patient Name

Patient Address

Patient Data

Medical Information

Please upload any files you can make available (reports, pictures, scans).

Desired Treatment

 Information Service only (80.-Euro)*
 Medical Expertise only (250.-Euro)*
 Full Referral Services (300-.Euro)*
 I will be travelling with a companion*

 Additional Visa Assistance (300.-Euro)*
 Personal services (Fee per hour, see TOR)*
 Medical transportation (Third party fee)*

Desired Services (Note: There is a general processing fee of 50.-Euro)

* Click on the label to see a short description of the services included in each package.

Preferred means of Payment

Confirmation: Based on the Terms of Reference (TOR), of which I have taken notice, I confirm that I require German Hospital Service Ltd. to provide the above mentioned services.

Confidentiality Statement
German Hopital Service Ltd. confirms that any personal and medical information which is received from patients and clients will be treated with utmost confidentiality and will only be made available to hospitals or phyicians in the course of arranging the services ordered by the clients.
The clients permit this restricted use of confidential data.

Type your name as signature