Application for service
Please answer questions below to start a successful communication - let us bring you the best-tailored medical experience. We will get back to you as soon as we get the application and keep customizing together.
Name, surname *
Email *
Phone number *
Citizenship *
Country of Residence *
I am travelling as *
Required
I am travelling *
Required
Number of people travelling *
I am interested in receiving medical service (please mention) *
Provisional Date of Arrival *
MM
/
DD
/
YYYY
Is personal assistance in the clinic required? (A personal guide during your stay in the clinic) *
Are travel arrangements required? *
Is lodging and catering required? *
Are local transfers required? *
Are translation services required? *
Is visa application assistance required? *
If interested in other activities besides medical treatment, list them below
Please let us know if any special requirements are needed or anything else we would need to know:
Submit
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