ABOUT US
SERVICES
WHAT TO DO
EMERGENCY
CHECK UP
REHABILITATION
PATIENT FORM
CONTACT US
PATIENT REGISTRATION FORM
PATIENT
Name (First, Middle, Last)   
Occupation   
Address   
City   
State/Province/Region   
Postal code   
Country   
Telephone   
  (Include Country Code and City Code)
Fax   
    (Include Country Code and City Code)
E-mail   
  Sex 
 
Height (cm) 
  Weight (kg)
Diagnosis (diagnoses in 
order of significance) 		  
Reason of inquiry   
Please describe you 
current medical problem 
and treatment to date 		  
Preferred country of 
treatment and desired 
terms 		  
Source of inquiry   
CONTACT PERSON
Name (First, Middle, Last)   
Occupation   
Telephone   
  (Include Country Code and City Code)
Fax   
    (Include Country Code and City Code)
E-mail   
Please add any other 
information you believe 
will be helpful 		  
 
Thank you for requesting at International Medical Service. We will make every effort to process your inquiry as quickly as possible.

 

  About Us | Services | What to do | Emergency | Check Up
Rehabilitation | Patient Form | Charges | Disclaimer | Contact Us | Site Map     © International Medical Service. All rights reserved.