Close

Kontakt EN

Contact Form

You can request medical support and a tailormade package by filling in this form.





Contact Information (required)

Name

Degree

E-Mail

Phone (with international prefix)

Address

Country

Medical Information (optional)

Age

Gender

Medical reason for request

Actual medical condition

Acute pain
yesno

Carried out examinations (with date) and results

Additional Information

Upload your File(s)