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© Health Service International GmbH
All Rights Reserved
 
Cost Information
 
German university clinics offer medical services for fixed rates. This makes the cost calculation for patients very easy. Likewise, the services rendered by Health Service International will be charged to the patients in detail. We accept the following credit cards:

 
 
Application form (for ambulatory and therapy in hospital)
 
*Indicates a required field
   
Patient Information

*Family Name
*Given Name
Gender Male   Female
Date of Birth
Mailing Address
City
Postal Code
Country
*E-mail
Telephone
Fax
Passport Number
Patient Marital Status
Single
Married
Divorced
Widowed
   
Method of Payment
Method of Payment
Self Pay
Embassy Sponsored
Embasssy Name:
Insurance
Insurance Company Name:

Policy:
Other Please specify:
 
Referal Source Information

Contact Name
Referring Organization
Telephone
Fax
E-mail
Mailing Address
City
Postal Code
Country
 
Appointment Information

Has the patient ever been to Health Service International ?
No
Yes
HSI History:
 
When is the patient available for an appointment (specify time period)
Appointment Type
New
Follow Up
Referral
Does the patient need an interpreter?
No
Yes
Language needed:
  
 
Medical Information
Medical Question or Concern
Brief History of the Problem
Other Medical Problems/Surgeries

In addition to the above information, please send via fax, e-mail or separate courier a current and complete Medical Report, including films (X-ray, CT Scan, MRI, Ultrasound), pathology slides and results of radiological, diagnostic and pathology studies. Please include a copy of this completed form with these materials.

The information requested above should be sent to:

Health Service International GmbH
Theodor-Kutzer-Ufer 1-3
D-68167 Mannheim (Germany)
Tel.: +49 621 1782 87-12
Fax: +49 621 1782 87-15
E-Mail: info@healthservice-int.com
 
Referral Source Information
How did you first hear about Health Service International ?

Please check one.
Friend/Relative/Former Patient
My Doctor
My Company or Employer
Radio/Television/Newspaper
Internet Search
Health Service International Website
Advertisement
Contact with Health Service International Representative
Please specify who:
   
Other.
Please Specify: