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What is your relation to the patient?*
Please provide the following information:
Please provide information about
the patient this enquiry is for:
Last Name*
Please spell your name the same way as it appears in official documents such as passport or drivers license.
Patient Last Name*
Please spell the patients name the same way as it appears in official documents such as passport or drivers license.
First Name*
Patient First Name*
Gender*
Patient Gender*
Date of birth*
Patient Date of birth*
Address*
Street Adress + No. City ZIP / Postal Code Country
Patient Address*
Street Address + No. City ZIP / Postal Code Country
Phone number*
Patient Phone number*
E-mail address*
Patient E-mail address*
Who do we contact for communication about this enquiry?
Applicant Name*
Applicant E-mail address*
Applicant Phone number*

Do you have a medical insurance?*
- Yes
- No
- Other
Does the patient have a medical insurance?*
- Yes
- No
- Other
If yes, or other: Which insurance company or other third party payer?
What is the primary medical issue / diagnosis? Please describe the health condition(s) for which you are seeking care or medical treatment.*
What is the primary medical issue / diagnosis? Please describe the health condition(s) for which the patient is seeking care or medical treatment.*
What is your request or expectation?*
What is the patients request or expectation?*

What is your preferred period/date of treatment & travel*
What is the preferred period/date of treatment & travel of the patient?*
Have you been admitted to a hospital outside of The Netherlands for longer than 24 hours within the last 2 years?*
Has the patient been admitted to a hospital outside of The Netherlands for longer than 24 hours within the last 2 years?*
Have you visited The Netherlands before?*
Has the patient visited The Netherlands before?*
What is your preferred language?*
What is the preferred language of the patient?*

Please check your enquiry details before submission*
- In case of treatment, I agree to pay by wire transfer
Please check your enquiry details before submission*
- In case of treatment, I agree to pay by wire transfer on behalf of the patient.
Summary of your request {all_fields}
Consent
I agree with the privacy policy of IPC.
Consent
On behalf of the patientI agree with the privacy policy of IPC.
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