Note: All fields in Sections 1, 2, 3 and 6 are required.




 

  

  
INQUIRY FORM 
  
 
 

  

  
Your
  Name
  
  

  

  
    
  
  
  
 
 

  

  

   
PERSONAL DETAILS 
  
  
  

  
 
  
 
 

  

  
1.1
  Patient’s Full Name 
  
  

  

  
      

  
  
  
 
 

  

  
1.2
  Gender 
  
  

  

  
  
  
  
  
 
 

  

  
1.3
  Date of Birth 
  
  

  

  
  
  
  
  
 
 

  

  
1.4
  Age 
  
  

  

  
  
  
  
  
 
 

  

  
1.5
  Country 
  
  

  

  
  
  
  
  
 
 

  

  

   
CONTACT DETAILS 
  
  
  

  
 
  
 
 

  

  
2.1    Email
  address
  
  

  

  
  
  
  
  
 
 

  

  
2.2
  Cell Phone number 
  
  

  

  
  
  
  
  
 
 

  

  
2.3
  Home address 
  
  

  

  
  
  
  
  
 
 

  

  
2.4
  Occupation 
  
  

  

  
  
  
  
  
 
 

  

  
2.5
  Phone number 
  
  

  

  
    
  
  
  
 
 

  

  
2.6
  Work address 
  
  

  

  
    
  
  
  
 
 

  

  

   
YOUR MEDICAL INQUIRY 
  
  
  

  
 
  
 
 

  

  
3.1
  Are you interested in any of our proposals? 
  
  

  

  
    
  
  
  
  

  
 
  
* Please
  attach at least two (2) photos of your current condition (where applies) 
  
 
 

  

  
3.2
  Required medical procedure  
  
  

  

  
    
  
  
  
 
 

  

  
3.3
  Present medical/health condition *
  
  

  

  
    
  
  
  
 
 

  

  
3.4
  Provide details in relation to your inquiry 
  
  

  

  
    
  
  
  
 
 

  

  
3.5
  Estimate the cost of the medical procedure? 
  
  

  
From
  €        To € 
  
 
 

  

  
3.6
  Which are your post-procedure expectations? 
  
  

  

  
   
  
  
  
 
 

  

  

   
PLANNING YOUR TRIP 
  
  
  

  
Select/complete
  the fields of services you are interested for. 
  
 
 

  

  
4.1
  Air ticket 
  

   
 Yes 
   
 No 
  
  
  

  
If
  Yes, please compete: 
  
Dates:
  
  
  
  
  
Country
  & City:     
  
From/To (please indicate origin/return airport): 
  
      


  
  
  
 
 

  

  
4.2
  Accommodation 
  

   
 Yes 
   
 No 
  
  
 
  
 
  
If you are travelling with companion(s), please complete section
  4.4.
  
  

  
If
  Yes, please select: 
  

   
Single Room   
   
Double Room *
   
Private accommodation 
  
  
Category
  of hotel or type of property:  
  

   
3* hotel 
   
4* hotel 
   
5* hotel
   
Private accommodation 
   
Other:
  
  
  

  
Duration
  of Stay:  (nights) 
  
 
  
Dates: 
  
  
 
  
Basis
  

   
Bed & breakfast
   
Half Board 
   
Full Board
   
All inclusive
  
  
 
  
 
 

  

  
4.3
  Airport transfers (return: airport-hotel-airport) 
  

   
Yes           
   
No
  
  
  

  
If
  Yes, please select: 
  

   
Private car/taxi
  
  

   
Private mini-van (6 seats) 
   
Wheelchair accessible vehicle 
   
Luxury Limousine 
  
  
 
 

  

  
4.4
  Number of companions: …..  / Full Names:  
  
1.
  
  
2.
  
3.
  
  
  

  
Relation
  
  
1.  
  
2.  
  
3.  
  
  

  
Accommodation
  
  
Sharing a double
  room (with patient) 
  
Single
  room
  
Other: 
  
 
 

  

  

   
Estimate the cost of all the above services
       selected (for all participants): € (please
       complete) 
  
  
  

  

   
Where did you find us? 
  
  
 (please complete)