Etape 1

By completing the form below, our team is committed to responding to you, with :

The response of our medical team for your case.
A detailed estimate, according to your specific case, for an all inclusive stay (Medical treatment, clinic, surgeon, stay and transfers)

This quote will be clear and without hidden fees to help you manage your budget.

My request

Treatment 1 *

Treatment 2

When would you like to come for your intervention * ?

My remarks or my questions to the medical team (Detail and specify your request as much as possible)

My contacts

Civility *

Mrs Mr

Name *

First name *

Date of birth *

Nationality

Country of residence

Mobile phone *

Phone

At what time did you prefer to be contacted ?

E-mail *

Choose your password *

Confirm your password *

Your e-mail and your password will allow you to connect to your customer area and follow the evolution of your request later

We respect your privacy; your medical file will be communicated only to the doctor.

I have read and accept the privacy policy and terms of sale

(*) : required fields