Please fill in the Form by giving information details as below
Sender's Information
Name of Sender(Mr/Mrs/Ms)
Mobile/WhatsApp Number
Email
Relationship to the patient (Father, husband, wife etc.)
Patient's Information
Full name of Patient (as per Passport) Mr/Mrs/Ms
What is your chief medical complaint
Gender(Male/Female)
Date of Birth (as per Passport)
Nationality/ Country of Residence
Date of intended travel to the Hospital
Mobile/WhatsApp Number
Email
Medical Details
For how long you have been sick?
Did you get treated at your country?
Do you have any current medical report?
Select mode of payment (If you select International Medical Card, You need to write full details
of the card in the Remark box provided)
Cash/ International Credit Card/ International Medical Card
Remarks
( If you have more to tell us, Please feel free to do so)
