Your case assessment

Your details

So that we can get back to you.

Last name *

First name *

Country of residence *

Nationality *

Phone / WhatsApp *

Email *

How would you prefer to be contacted? *

WhatsApp Phone Email

What do you need?

Tell us what you expect from us. You may tick more than one answer.

I am looking for: *

A health check-up A diagnosis / second opinion Treatment for a condition I am not sure yet / I need guidance

Your medical situation

These details help our doctors understand your case.

Have you already received a diagnosis? *

Yes No I am not sure

Have you already had treatment or surgery? *

Yes No

Medical documents

Do you have medical documents to send us? *

I have no documents Medical report Blood tests MRI / CT scan X-ray / Ultrasound Prescription Surgical report Other

PDF, JPG or PNG — up to 5 files, 5 MB each.

Your trip

Tick only what you need: the questions below adapt to your answers.

Which services do you need? *

I only need the medical arrangements Visa Airport transport Accommodation Transport during my stay

Your availability

When would you like to come? *

As soon as possible In the coming weeks In 1 to 3 months In more than 3 months I am not sure yet

Approximate length of stay *

Less than a week 1 to 2 weeks 2 to 4 weeks More than a month I am not sure

Anything else

Is there anything else you would like to tell us?

Summary

Please check your answers before sending them. Use “Previous” to go back and correct them.

I agree that Medic Interface may use the information provided in order to review my request and contact me about my care. *

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Your details

What do you need?

Your medical situation

Medical documents

Your trip

Visa

Accommodation

Transport during my stay

Your availability

Anything else

Summary

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