Appointment Form

Patient Surname

Patient Name

Date of Birth

City of the patient

Country of the patient

Phone

e-Mail

Diagnose (If known)

Medical History of the patient

Please add medical reports with pdf, jpeg format

Medical Director

Medical Facilities

Department

Possible Visit Date:

Possible Visit Time:

will be confirmed by MediVoucher.

Surname

Name

Relationship Degree

e-Mail

Phone

Notes: This appointment only for First Examination. Further treatments and tests schedule will be given by medical facility or medical director.