Medical tourism form

2455

International Treatment Inquiry
Dear patient, dear requestor, In order to evaluate if we can offer a reasonable treatment option and to prepare an individual treatment plan, the medical specialists of Astghik medical center require some information and medical data. Please note that we cannot deal with your inquiry unless you provide us this form completed in English, or Russian and the necessary up-to-date medical reports in English or Russian:
Please complete this form in English or Russian.
Patient Data

Please Select    
Title    
First name*    
Last name*    
Gender*    


Date of birth*    


Address*    
Zip code and city*    
Phone    
Fax    
Email*    
Contact person (if different from patient)    

Do you require visa assistance? (invitation for the embassy)

IO-Case Number (if provided)    
Medical Information

1. Disease(s) / Symptom(s) to be treated*    
2. What do you expect from your appointment / treatment in Astghik medical center
(specific indication / desired treatment)?*    
3. Select specialty department (only indicate if known)    

4. Which diagnostic tests were performed during the last 3-6 months?
(please provide us with essential reports in English or Russian)
Imaging techniques

MRICT/PET-CTSonographyX-rayAngiographyHeart catheter

Endoscopy (Gastroscopy, Colonoscopy, bronchoscopy, etc.)

Other

Laboratory tests
Routine tests (blood count, etc.)
Special tests

Histology
Histological test; Tissue sample taken on (DD/MM/YYYY):

5. Which treatments have been performed for the disease(s)/symptom(s) mentioned above?

Kind of Treatment Description (Approximate) Duration
(Operation, medication, irradiated body part, etc.) On/From (MM/YYYY) To (MM/YYYY) Ongoing
Operation / Intervention (e.g. heart catheter)
Drug Therapy (e.g. Chemotherapy other medication)
Irradiation please add previous radiation treatment protocols
Other


6. Please indicate further relevant diagnoses:    


7. Do(es) you/the patient have any infections at present?*     UnknownNoYes
Description    


8. Do(es) you/the patient have any open wounds at present?*     UnknownNoYes

location


9. Please indicate your / the patient's present mobility status?*
not limitedoften / usually dependent on a wheel chair(partially) bedriddenin intensive care unit


10. Additional information, for example: contact data of treating physician in country of residence (max. 400 characters)



11. Desired appointment date (DD/MM/YYYY)

Earliest possible appointment date

Medical Reports

Please provide copies of the required medical documents (no originals)*
I will send you the copies of the medical documents along with this form via e-mail.(accepted files, e.g.: .pdf, jpg, .doc; max. 10 MB per document; not accepted: zip-, rar- or bitmap files)





I will upload DICOM files (e.g. MRI, CT scan, heart catheter) via Internet (possible immediately after sending of this form or later via an upload-link which we will provide automatically.)


I will send DICOM files on CD-ROM/DVD via conventional mail.


I/the patient do(es) not suffer from any disease; I desire an appointment for an out-patient check-up in the specialty department(s) indicated above.



How did you learn about Astghik medical center?Internet
InternetTreating physician/hospitalFamily members/friendsBusiness partnersEmployerAstghik medical center staff memberPress releasesEmbassy/Governmental institutionHealth insuranceOther




I am requesting a copy of this inquiry form, including medical data.
Note on data privacy protection: Astghik medical center will transfer the data without using any special technological encryption to the supplied email address. By requesting a copy, I am consenting to the transfer of medical data and I am also consenting to the further email communication without any special data encryption for subsequent correspondence (for example: issuance of cost estimate and treatment offer). In case I am not the patient myself, I confirm that I have the patient's permission to request this copy via unencrypted email and to consent to the further related correspondence to be sent via unencrypted email.*



I agree that the data and documents I uploaded via this telemedicine portal will be saved for six months. In case of a subsequent treatment or consultation by Astghik medical center I furthermore agree that the data and documents will be saved in my personal patient file according to the Russian national legal requirements. In case I do not decide in favor of a treatment or consultation by Astghik medical center all data and documents will be deleted automatically and irrevocably after six months.*