PATIENT REGISTRATION FORM

PATIENT

Name (First, Middle, Last)

Birthdate (mm/dd/yyyy)

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

HERE YOU CAN ATTACH AND SEND FILES OF MEDICAL DOCUMENTS

File 1

File 2

File 3

Thank you for requesting at International Medical Service. We will make every effort to process your inquiry as quickly as possible.

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