Application form

This application form is strictly confidential and as such all personal data and medical information contained therein shall be used exclusively for the purpose of treatment and administrative records.

Please fill in all fields marked with *

Title*
First name*
Surname*
Date of birth*
Street*
City*
Post code*
Country*
E-mail address
Telephone/fax*
Mobile phone
I consent to my personal data and medical documentation (including examination and X-ray results) being used for the purpose of treatment.
What kind of medical services are you interested in?
What kind of our extra services are you interested in?
Your the nearest airport?
When would you like to come?
How did you learn about us? Internet (Google, Yahoo, MSN) www.treatmentabroad.net Sponsored links Leaflet Newspapers, magazines Family, friends Other