Mobile : +91 98100 68241
PATIENT REGISTRATION
Name :
E-mail :
City :
Country :
Phone :
Mobile :
Best Time to call
Is this Inquiry for yourself or on behalf of someone else ?
  Self
  Friend/Relative
  A Minor
What sort of procedure(s) are you considering?
  Cardiology/Cardio thoracic (Angioplasty/CABG)
  Cosmetic/Plastic
  Gastroenterology
  Neurology/Neurosurgery
  Oncology
  Orthopedics (Joint Replacement)
  Opthalmology
  Dental
  Other (please specify)
Why are you considering treatment in India?
  Access to lower cost care
  Access to high quality, personalized care
  Access to treatment not yet available here
  Waiting period too long here
  Anonymity
  Opportunity to couple treatment with a vacation
  Other (please specify)
How urgent is your need?
  Immediate
  1 - 2 months
  2 - 3 months
  3 - 4 months
Do you have a doctor who will help you obtain treatment overseas?
  Yes, I have a doctor
  No, I need a doctor
  No, I don't think I need a doctor
Have you discussed alternatives with a doctor?
  Yes
  No
Have you ever traveled outside your country?
  Yes, often
  Yes, a few times
  Yes, once
  No, never
How do you intend to pay for your treatment?
  Cash
  Credit
  Insurance reimbursement
  Other
  Don't know
Any other remarks or special requests:
 
Home About us Medical tourism Contact us Enquiry FAQsSitemap
Copyright © 2006 | mediminds | All Rights Reserved|
Terms of Use | designed & developed by Infinite Solution