Treatment Inquiry Form

If you are not sure which one is the best offer or not have the time to choose an offer, mediassist will gladly assist you in finding the best treatment available.
Simply send mediassist your online request and tell which service you want. mediassist will give you a selection of clinics which offer your treatment. Alternatively, mediassist can arrange the travel organisation in accordance with the treatment plan.

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1

Gender

Name

Surname

Phone NumberPreferably Mobile Phone with WhatsApp

Date of Birth

Planned arrival

Planned departure

Requested treatment

Treatment Preferences (detailed description)

0 /

Travel Preferences (detailed description)

Wishes for leisureOptional

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