Enquiry form

Questionnaire for FIRST INFO on PATIENT

You may also request for the French or English customized format.

Response time for receiving information to process your records for Treatment Plan & Quotes:

1. Last Name, First Name, (Middle initial)*

2. Gender*

3. Date of Birth*

4. Nationality, Country of residence*

5. Conversational language*

6. Complete address*

7. E-mail

8. Phone*

9. Fax

11. About your medical condition: Your Prognoses / Diagnosis or clinical and physical condition*

Important:
*Every person traveling with patient must bear a valid passport for 6 [six] months from the planned date of travel.

**Some countries listed herein, may require a visa subject to passport holder's nationality.

DISCLAIMER

• Prices will be for rough planning purposes only to assist the patient in understanding the possible range of costs.
• Actual estimates for procedure, recovery as in-patient and out-patient which includes accommodation in an European style facility, cannot be accurately provided until the patient expresses the need for additional services, and the physcian-designate releases the final report to qualify patient for requested treatment.
• The cost ranges provided are based upon our best understanding of the patient's condition at the time of contact and do not represent a minimum or maximum potential cost.

© 2007 OMS Canada Inc.