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> Request on medical tourism estimation
sender
name
Area
E-mail
Tel
Patient
Name
Nationality
Date of birth
Age/Sex
Arrival scheduled date and time
Information of flight
(Airlines, Flight No., Arrival time)
Kinds of treatment desired
Disease or operation history
(Write detailed as possible )
Allergy
(Write detailed as possible and If there is nothing, please write 'nothing'. )
Present status
Can you send data for X ray, MRI, CT-scan, etc.?
Y
N
Things hospital needs to check about patients except the above.
(If there is nothing, please write 'nothing'.)
The necessity of interpreting
(Please inform us of the language patient or guardian speak)
Accompany with guardian
(If accompanied, how many guardians will be.)
Patient contact
name
relation
oneself
Tel
E-mail
address
fax
Guardian contact
name
relation
oneself
Tel
E-mail
address
fax
Contact for emergency
name
relation
oneself
Tel
E-mail
address
fax
Punch in the left numbers
