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1. Patient information
What is your relation to the patient?*
Patient details
Please provide information about the patient this enquiry is for. These will be used for registration only.
Gender
- Male
- Female
- Other
First Name*
Last Name*
Date of birth*
Street and no.*
City*
ZIP/Postal code*
Country*
Country
Patient e-mail address*
Patient phone number*
Contact information
Please provide the information of the person we can contact about this enquiry.
Name*
Phone number*
E-mail address*

2. Medical concern
What is the primary medical issue / diagnosis?
Please describe the health conditions for which you are seeking care or medical treatment.
Treatment
What do you expect from this request?
Please describe your desired outcome.
Outcome
Do you have a medical insurance?*
- Yes
- No
- Other
Which insurance company or third party payer?
Describe your insurance situation

3. Appointment
Preferred travel and treatment time
What is your preferred period/date of treatment & travel?*
Travel history and preferences
This information will be used for registration purposes only.
Have you been admitted to a hospital outside of The Netherlands for longer than 24 hours within the last 2 years?*
- Yes
- No
Have you visited The Netherlands before?*
- Yes
- No
What is your preferred language?*

4. Review & submit
Summary of your request {all_fields}
Terms and conditions
Please agree with the terms and conditions upon submission.
Please check your enquiry details before submission*
- In case of treatment, I agree to pay by wire transfer on behalf of the patient
Consent*
I agree with the privacy policy of IPC.*
Name

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