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: 3-7 working days

1. Last Name, First Name, (Middle initial)*
2. Gender*
3. Date of Birth*
4. Nationality, Country of residence*
5. Do you have a valid passport?
   
6. Conversational language*
7. Complete address*
8. E-mail
9. Phone*
10. Fax
11. About your medical condition: Your Prognoses / Diagnosis or clinical and physical condition*

IMPORTANT:

If the enquiry realtes to organ transplant, the following reports must accompany the enquiry:

1.  Blood Type

2.  HLA tissue Typing Report

WHAT IS A HLA REPORT?

HLA - Definition
[ Human Leukocyte Antigen ]

HLA Tissue Typing is a group of procedures that determines the type of histocompatibility antigens on a person's cells or tissues.

This procedure is typically used prior to transplantation of tissues or organs.

A procedure involving a test or a series of tests to determine the compatibility of tissues from a prospective donor and a recipient prior to transplantation. The immunological response of a recipient to a transplant from a donor is directed against many cell-surface histocompatibility antigens controlled by genes at many different loci. However, one of these loci, the major histocompatibility complex (MHC), controls antigens that evoke the strongest immunological response. The human MHC is known as the HLA system, which stands for the first (A) human leukocyte blood group system discovered.

The success of transplantation is greatly dependent on the degree of histocompatibility (identity) between the donor and recipient, which is determined by the HLA complex. When the donor and recipient have a low degree of histocompatibility, the organ is said to be mismatched, and the recipient mounts an immune response against the donor antigen. By laboratory testing, the degree of antigenic similarity between the donor and the recipient and the degree of preexisting recipient sensitization to donor antigens [and therefore preformed antibodies] can be determined.
This is known as cross-matching.

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

**Countries we work with, 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.  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.
• 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 physician-designate releases the final report to qualify patient for requested treatment.

© 2009 OMS Canada Inc.