Please note: Although it is most unlikely that you will experience
any problems responding to this form, certain non-standard browsers will
not respond properly. If you experience any difficulties, (or if you are
not using a forms-capable browser) you may email your response to this
form to: firstname.lastname@example.org.
Sarah Aharonson 23, Ramat-Gan 52293, ISRAEL
TEL: +972 3 674 16 76 FAX: +972 3 674 17 76
email to: email@example.com
Patient Inquiry Information Form
The following patient information form is designed for patients, family
members and others who are considering treatment or diagnostic consultation
By completing the form below, you will help us answer your questions
quickly. If a decision is then made to come to Israel for consultation
or treatment, this information will greatly assist us in preparing your
All patient information is strictly confidential.
You may post this completed form through the net by clicking on the
'submit' button below; print the form and fax it to us at the above fax
number; or mail it to the above address.
Name of Person Making Inquiry:
Relationship to Patient:
Patient Date of Birth:
Patient Medical Diagnosis:
What medical records, tests and physician reports are available?
Medical Records and Tests:
If the patient is planning to come to Israel, when will he/she arrive?
Date of Arrival:
Should a decision be made to pursue treatment or consultation in Israel,
what payment method will be used?
Method of Payment:
Will patient require interpreter services? In what language?
Interpreter Services Desired:
Will the patient be arriving alone?
Would the patient/family like assistance in reserving local accommodations?
Please list requirements (e.g., room type, cooking facilities, transportation,
cellular phone, etc.)
Please provide any additional information or comments regarding the
patient's diagnosis and condition which you believe to be relevant.