1. Full Name*:

2. Full Name (as in the passport for traveling abroad)*:

3. Date and year of birth:

4. Profession (place of work and position, in the case of presence of harmful working conditions - indicate occupational hazard):

5. Address and place of residence – country, postal code, town, street, number of house and apartment:

6. Citizenship:

7. Phone (with area code):

Факс:

8. E-mail*:

9. The data of your passport for traveling abroad:

Code:

Passport No.:

Date of Issue:

Date of Expiry:

Authority:

10. In the presence of the patient's authorized representative in Russia or in Germany specify the data:

Full Name:

Address and place of residence – country, postal code, town, street, number of house and apartment:

Phone (with area code):

Fax:

E-mail:

11. Your basic disease:

12. Diagnosis (specify the diagnosis, the date of its establishment; in the presence of complications - indicate comorbidities and surgeries):

13. Disease condition currently:

14. Treatment conducted to date:

15. The purpose of your visit to Germany (clarification of the diagnosis):

Conservative treatment  yes no
Surgery  yes no
Rehabilitation treatment  yes no
Spa treatment  yes no

16. Under what conditions you would like to get medical help?

Ambulatory treatment  yes no
Hospital treatment  yes no

17. What help do you expect from the company, and how can we help you:

Flight reservations  yes no
Airline (please specify)
Class:  Economy business-class
Visa  yes no

Book hotel for the patient during the stay outside the hospital
 yes no
Book hotel for an accompanying person
 yes no
Class:  ** - *** *** - **** **** - *****

18. Translation services (additional or hourly payment):

Translation of an extract from the medical history
 yes no
Translators support for admission to the hospital and at discharge
 yes no
Translators support in surveys and interviews
 yes no
Fulltime translators support
 yes no

19. Other desired services not included in the list of the above services, for example, a transfer in both directions:

20. Expected arrival time and place of arrival, if arrival details is already known:

Date and place of filling application: