Complete your medical travel patient registration

To complete your patient registration, please fill out the form below and submit it to us.

Medical Travel Patient Registry

Patient Information “Short Form”

All items must be answered. If you choose not to provide information in any one item, please insert “none” or “NA” (not applicable) in the designated space.

Your name *

Your email *

Your location *

Your preferred method of contact *

EmailPhone

Your phone number (optional)

Your planned dates of travel *

Your medical destination (city, country) *

Your medical travel company (if any)

Your Message *

[textarea-440* your-message 50x5 class:contact7]

Please confirm that you are not a robot:[recaptcha]

Your registration to the Patient Registry includes a subscription to our newsletter and other emails related to medical travel that we may send you from time to time. We respect your privacy and will not sell or otherwise use your email address. You may unsubscribe or change your preferences at any time.