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ASK-A-HOSPITAL
International Patient Services Inquiry Form
Featured American Hospitals and Health
Service Organizations on Medical Resources USA
may be contacted by using the form below. Please note:
the information that you supply below will be provided
to the Hospitals and Health Service Organizations that
you select.
Select a Hospital / Health Service
(required) |
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Contact Information (required) |
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Your Name:
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Address:
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City:
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State/Province:
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Country:
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Postal /ZIP Code:
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Telephone:
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Facsimile:
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E-mail:
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Patient Information |
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Date of Birth (d/m/y):
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Sex:
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Male
Female
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If you ARE NOT the patient... |
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Patient Name:
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Patient's Relationship to You:
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Medical Problem (Reason
for your inquiry) |
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Service Requested (Please
check all that apply)
Second Opinion (
By correspondence only
In person )
Treatment
Diagnostic Tests
Complete Physical Exam
Other:
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Logistical Information (Please
check all that apply)
If services are rendered in the U.S., patient would:
Yes
travel with a companion, guardian or assistant
need translation services (if yes, what language
)
need special dietary arrangements (if yes,describe
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need special care arrangements (if yes,describe
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need special equipment (if yes,describe
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need transportation to and from airport
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Insurance/Form of Payment
Should the patient receive services, they
would pay through:
Cash,
Government,
Insurance (Name):
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Physician Information
If necessary, may we contact your physician/s
for further information? |
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Physician Name:
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Telephone:
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Facsimile:
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E-mail:
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