Ouverture de dossier - Mon Séjour Médical

Questionnaire

The purpose of this questionnaire is to obtain basic information for the preparation and organization of your medical stay.

First name

Name

E-mail

Phone

Gender

Occupation

Date of birth

Full address

Information on the medical treatment sought

Type of treatment desired

Current diagnosis

Relevant medical history

Desired date for treatment

Check if you will need a preliminary medical consultation

Stay details

Desired Duration of Medical Stay

Estimated start date of stay

Estimated end date of stay

Approximate length of stay (days)

Check if you want to be accompanied

Number of accompanying person(s)

Relationship with accompanying person(s)

Insurance

Check if you have medical insurance covering treatment abroad

Name of insurer

Insurance policy number

Scope of coverage

Emergency contact details

Emergency contact person

Relationship with you

Emergency telephone number (with international code)

E-mail address

Declarations and authorizations

Data Privacy

By signing this form, you acknowledge that your personal and medical information will be used only for the purpose of organizing your medical stay, in accordance with current data protection legislation.

I authorize the processing of my personal and medical data as part of the organization of my medical stay

Medical consent

I acknowledge that I have provided accurate and complete information and I understand that this information is necessary to ensure the best quality of service in organizing my medical stay.

I confirm that all information provided in this form is accurate.

Signature

Full name (in capital letters)

Date

Amount to be paid

Thank you for your trust. Our team will contact you as soon as possible to finalize the organization of your medical stay.