How to Become an International Patient
International Patient Intake Form
Please provide your information below. Thank you!
Your Contact Information
Your full name
(Required)
Relationship to patient
(Required)
Your phone number
(Required)
Your email address
(Required)
Your primary language
(Required)
Brief description of your request
(Required)
Patient Information
Patient's name (last, first, middle)
(Required)
Patient's date of birth (month, day, year)
(Required)
MM slash DD slash YYYY
Patient's sex
(Required)
Female
Male
Permanent address
City, State/Province, Country
(Required)
Temporary/local address
(Required)
Temporary/local address city, state/province, country
(Required)
Patient's suspected diagnosis
Travel Companion Information
Patient Travel Companion #1
Full Name
(Required)
Phone number
(Required)
Relationship to patient
(Required)
Clinical Information
Referring physician name
Referring physician phone number
Referring physician email
Referring hospital name
Referring hospital address
Do you have medical images ready to share?
(Required)
Yes
No
? What are they
Please upload your medical records and imaging files here
Max. file size: 50 MB.
Do you have recent medical reports translated into English?
Yes
No reports
I have reports but they are not in English
Payment Method (select from list)
(Required)
Insured
Government sponsored
Self-pay
Other
Patient Coordinator
Have you been in contact with one of our Patient Coordinators? (If yes, please specify who.)
Fatemeh Jokar BSN
No
Travel Information
When do you plan to travel to receive medical services at Ordibehesht Hospital?
(Required)
What country will you be traveling from?
(Required)
? How did you hear about us
Referring physician
Friend or Family member
Employer
News
Instagram
Online search
Ordibehesht Hospital Website
Other
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