A1 Medical Center Inquiry

Please fill out this form and send to us pressing Submit-Inquiry-Button.

Should you have problem with filling out and sending this form, please send us your inquiry via Email to health@a1-medical-center.com

Personal Details

Title*
- Mr.
- Ms.
- Mrs.
Patients` First Name*
Patients` Last Name*
Patients`Date of Birth*
Contact person (First and Last Name)
Patients`Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone*
Email*
Enter Email Confirm Email
Inquiry Details
I prefer a patient consultant to contact me for further assistance.
1. What is the disease you would like to be treated for:*
2. Remarks
3. I would like to ...*
- ... be treated within the next 30 days
- ... be treated within the next 1-3 months
- ... travel to one of our center for an in-person medical examination and treatment evaluation
- I have not decided when I would like be treated yet
4. Have you ever been treated in our center before?*
- Yes
- No

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