Contact form

[int] Kontaktformular (EN)

Salutation

Title

Patient’s first name

Patient’s last name

Date of birth

City

Country

Telephone number

Email address

I am interested in (multiple selection possible): *

Diagnostics

Treatment

Second opinion (doctor's appointment)

Second opinion (remote consultation on the basis of submitted documents)

Diagnosis

Diagnosis date

Other information regarding your illness and treatment received up to now, if any

Upload files (e.g. medical records)Allowed: *.zip, *.pdf, *.odt, *rtf, *.jpg, *.gif, *.docx

(max. 5 MB)

The patient is able to walk:

Yes

How did you know about our hospital?

Yes, I have read the information on the privacy policy and agree that my personal data will be electronically raised and stored. My personal data will be used only for the purposes of processing and responding to my inquiry. By submitting this contact form I agree to the processing of my personal data.*

Please solve the math equation and enter the result. This helps to avoid spam.

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