Ladisten Clinic™ International Services Request

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Fields marked with an * are required.

Patient Information
  Have you previously been
a patient at Ladisten Clinic?		 No
Yes    Ladisten Clinic number:
  Title:
  Patient name (please list name as it appears on passport):
  Last Name: *
  First Name: *
  Middle Name:
  Date of Birth:
(month/day/year)
  Patient's gender: * Male    Female
  Parent/Guardian Name (if patient is under age 18):
  Patient address: *
  City: *
  Province/Dept: *
  Postal code: *
  Country: *
  Phone: *
  Mobile phone:
  Fax:
  E-mail:
  Patient's primary language:
  Please note: If English is not your primary language, we strongly suggest use of a Ladisten Clinic interpreter.
  Interpreter Needed: No
Yes   Language:
  Will you need assistance in obtaining a visa to Ukraine? Yes
No
  Diagnosis
(please be specific):
  Your comment about desired procedures and treatment:
  Appointment date requested:
  First choice:
(day/month/year)
  Second choice:
(day/month/year)
  Appointment type requested:
  Consultation & Evaluation Surgery Rehabilitation
  Please note: We may ask to send a recent medical summary in English including diagnosis, pathology reports, and local physician's treatment plan. We will contact you regarding when and how to send this information. Please do not send x-ray films via mail.

Referring Person Information
  Referring person's name: (if applicable)
  Relationship to patient:
  Address:
  City:
  Province/Dept:
  Postal code:
  Country:
  Phone:
  Mobile phone:
  Fax:
  E-mail:

 

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