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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:
   
Best time(s) to call (please specify region and/or time zone):
  (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/Cardiothoracic
  Cosmetic/Plastic
  Gastroenterology
  Neurology/Neurosurgery
  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
     
Any other remarks or special requests:  (Optional)
 
     
 
 
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