German Medicine Net
Main Menu   About us   Help   FAQ   Sitemap   Service   Contact
Switch language: German Spanish Dutch Japanese Italian Danish Bulgarian Estonian Greek Lithuanian Portuguese Romanian Swedish Czech Russian Urdu Arabian American English Hungarian Polish French  
Home
 
Contact Form for non-german Patients
 
 
Last Name 
First name
Gender male female
BornYYYY-MM-DD
Street and Number
PCode, Place of Residence
Country
Phone
Fax
E-mail
Please let us know the name, address, phone, fax and email of your doctor in your country if you regard this information as helpful:
 
Please send me detailed information about your service.
 
I Have the following health problem (everything you are writing to us here will be treated with absolute confidentiality by us)::
 
I need the following medical services at short notice:
 
Please give me a rough estimate for the costs for the services named above.
 
Please write us more details about your requirements