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Patient Data

Please select:

Title:

Last name:*

First name:*

Gender:*

Date of birth:*

Adress:

Zip code and city/town:

Country:*

Medical Information

Disease(s) / Symptom (s) to be treated (please be specific)*

Reason for your inquiry (specific indication / desired treatment)*

Important:
We require medical documents to enable us to produce treatment recommendations and the cost estimate. The medical documents have to be:

up-to-date (not older than 3 months),
informative (for example: current status of the patient, last treatment, principal diagnosis and further conditions) and
in German or English..

You can attach them electronically here (as Zip file if necessary). Data over 2 MB (MRI images, etc.) should be sent via CD to the International Office.

Inquiries Neurosurgery:
In addition to the above mentioned documents we require up-to-date MRI images, which are not older than 3 months in case of inquiries for the neurosurgery department. Please note that we require images in the DICOM format (no jpeg or other image formats can be accepted). The images should be sent via CD to the International Office.

File Upload:

Additional information:

Desired date for treatment:

Contact Data

Please indicate how we can contact you:

Name of contact person (if different from patient):

E-mail:*

Phone (please include the international prefix):

Fax (please include the international prefix):

Do you require visa assistance?:

How did you learn about our medical center (check all that apply)?

Treating physician / hospital

Family member / Friends

Business partners

Employer

Heidelberg University Hospital staff member

Press releases

Embassy, Ministry of Health

Health insurance

Internet

Other (please specify):

Please complete this form in English or German

Patient Data

Medical Information

Contact Data

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