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Appointment – EN

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Doctor name*

Centers & Clinics*

Appointment Date*

Appointment Time*

Medical concern or request*

Choose Patient Information

Yourself

Someone Else

Patient*

First name Last name

Date of Birth*

Gender*

Nationality*

Phone Number*

Email*

Existing Patient?*

Yes

Hospital Number (HN)

Passport ID / ID Card*

Attach a copy of your ID card/passport*

Max. file size: 5 MB.

Country / Region*

Street address*

Town / City*

State*

Passcode / Zipcode*

I voluntarily agree to allow the healthcare staff at Hospital to provide care, treatment and procedure according to the standard of practice. I also agree to the healthcare staff access my health information in regard to the provided care, treatment and procedure. I acknowledge and understand that I have been informed about “Patient Rights” and “Privacy Policy”

I hereby acknowledge and consent the Hospital to send information about products, services, advertisements, or promotional programs that will benefit me via all channels I have given to the Hospital.*

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Contact Information

Full name*

Firstname – Lastname

Phone Number*

Email*

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