Home |  Login |  Contact Us

About IndUShealth The IndUShealth Advantage Patient Registration Our Partners

Patient Registration

If you are interested in learning more about how we can help you, please provide us the following general information about your needs. We will have one of our Case Managers get in touch with you to discuss details of how we can further assist you.

 
Name:
E-mail:
Phone:
(optional)
Best time to call:
(optional)
Referred by:
(optional)
Is this inquiry for yourself or on behalf of someone else? Myself
Someone Else
A Minor(Pediatric)
 
What sort of procedure(s) are you considering? (check all that apply) Cardiology
Cosmetic/Plastic
Gastroenterology
Neurology
Oncology
Orthopedics
Opthalmology
Dental
Other
 
Why are you considering overseas treatment? (check all that apply) Access to lower cost care
Access to high quality, personalized care
Access to treatments not yet available here
Ability to get treated more quickly
Better options for convalescent care
Anonymity
Opportunity to couple treatment with a vacation
Other
 
How urgent is your need? Immediate
1-2 months
3-5 months
6+ months
 
Do you have a doctor who will help you obtain treatment overseas? Yes, I have a doctor
No, I need a doctor
No, I don't think I need a doctor
 
Have you discussed alternatives with a doctor? Yes
No
 
Have you ever traveled outside North America?? Yes, often
Yes, a few times
Yes, once
No, never
 
How do you intend to pay for your treatment? Cash
Credit
Insurance reimbursement
Other
Don't know
 
Comments:
(optional)
 
Current Year:
(4-digit YYYY) (for anti-spam verification purposes)