International Patients' Form

Personal Information

Full Name

Date Of Birth

Gender

Country of Residence

Nationality

Passport Number (Optional)

Contact Information

Phone Number (Including Country Code)

WhatsApp Number

Email Address

Preferred Contact Method

Medical Information

Requested Department / Service

Main Concern / Medical Condition

Previous Medical History (Optional)

Previous Surgeries or Procedures (Optional)

Current Medications (Optional)

Allergies (if any)

Travel Information

Preferred Travel Dates (Optional)

Estimated Length of Stay (Optional)

Number of Accompanying Persons (Optional)

Preferred Support Services

Medical Reports & Images

Medical reports

Prescriptions

Laboratory results

Scans & Imaging

Photos related to the condition

Additional Notes

Any additional information or requests (Optional)

I confirm that the information provided is accurate. I consent to being contacted by Telescope Medical Center regarding my medical inquiry. I understand that all shared information will be handled confidentially.

Aesthetic Treatments

Medical Dermatology

Aesthetic Treatments

Medical Dermatology

Medical Tourism form

International Patients' Form