Patient Request Form - Лечение в Корее

How can we help you?
Choose all that apply for this trip*
- COMPREHENSIVE MEDICAL CHECK-UP:
- TREATMENT BASED ON CURRENT DIAGNOSIS:
- IVF (INFERTILITY TREATMENT)
- PLASTIC SURGERY
- KOREAN TRADITIONAL MEDICINE
- OTHERS
Patient’s medical records
Name*
Full Name
Date of Birth*
Date Format: MM slash DD slash YYYY
Address*
City Country
Phone Number*
Mobile
Email*
Height / Weight
How long have you had the symptoms?
First symptoms: What was the first reason you went to the hospital?
What kind of medical examinations/screenings did you go through for the above-mentioned symptoms?
What diagnosis did you receive?
Did you have a treatment for the above-mentioned diagnosis?
What kind of symptoms do you have now?
What are your doctor’s recommendations?
Other diseases in the past (Hepatitis, tuberculosis, diabetes, hypertension and etc.)
Allergies (Food, Medications and etc.)
Have you been through any surgeries in the past?
Do you take any medications during the last month? What are they?
Upload Medical Records
Drop files here or

Accepted file types: jpg, gif, png, doc, docx, pdf, txt, zip.

Flight information
Arrival Date
Date Format: MM slash DD slash YYYY
Departure Date
Date Format: MM slash DD slash YYYY
Flight Number
Do you need Visa support?
- Yes
- No
Are you willing to extend your stay upon the hospital request?
- Yes
- No
For how long? (days)
Accommodation
Accommodation requirements
Number of People traveling with you
Do you want us to send you information about cultural & entertainment options?
- Yes
- No
Your comments:
If you have any questions we are always at your disposal via phone, email, or skype. We are happy to assist you and solve your inquires!

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