Patient information and Service ordering Questionnaire
Please use this form to provide the necessary information on the patient, the medical situation, the desired treatment and services. To send, just use the button below. We need this information to process your treatment order, know which services you want and present the request to the medical specialists. If you do not want to send by using internet transfer, you can also print out the page and send it by mail or fax, possibly with any available medical documents or images on discs. The postal address is:
German Hospital Service, Destouchesstr. 1, 80803 München, Germany, Fax +49-416107059

Please enter your complete information for communication by mail.

Please enter your personal and  medical information for communication with the hospital.

Please order the services you want here.

Translation Services

To facilitate the presentation of medical documents, we suggest using the translation service

Patient Name

Patient Address

Patient Data

Medical Information

(Please replace the descriptions in the fields with your text)

Please upload any files you can make available (reports, pictures, scans).

Desired Treatment

Desired Services
Please indicate your choices
(Note: Plus the general processing fee of 50.-Euro)

 Information Service only (80.-Euro)*
 Medical Expertise only (250.-Euro)*
 Full Referral Services (300-.Euro)*
 I will be travelling with a companion*

 Additional Visa Assistance (400.-Euro)*
 Personal services (Fee/hour, see TOR)*
 Medical transportation (Third party fees)*

* Click on the label to see a short description of the services included in each package.

Preferred  means of Payment

Confirmation: Based on the Terms of Reference (TOR), of which I have taken notice, I confirm that I require German Hospital Service Ltd.  to provide the above mentioned services.

Confidentiality Statement
German Hopital Service Ltd. confirms that any personal and medical information which is received from patients and clients will be treated with utmost confidentiality and will only be made available to hospitals or phyicians in the course of arranging the services ordered by the clients.
The clients permit this restricted use of confidential data.

Type your name as signature