Medical concierge service proposal form

Case identification

Urgent File*

Yes
No

Please indicate

The CBIANET case N°:

Language spoken by the person:

Mission dates

Start of service:*

End of service:*

Patient informations

Last name :*

First name :*

Date of birth:*

Patient information in his/her country of residence

*

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Email*

Phone*

Patient information in the visited country

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Phone

Contact details of the family General Practitioner

Last Name:*

First Name:*

Specialty:

Street Address

Address Line 2

City

State / Province / Region

ZIP / Postal Code

Country

Email*

Phone

Details of a Contact Person

Last name:

First name:

Patient relationship:

Email

Phone

City

Specific demand

What type of service is required:*

Highest Quality
Classic Quality
Delivery of medication

Patient health

Needs a wheelchair
Need medicalized assistance
Ambulance
Light medical vehicle transportation
Car transport

Specific remarks relating to the request:

Attachment (if more than one use compressed file)

Application details:

Assistance in obtaining visas
Translators

Relationships with family:

Provision of a phone card
Communication of medical reports

Organization of medical appointments*

Yes
No

If yes, what sort?*

Hospital
Doctors
Specialists

Other requirements:

Medical Referrer
Contact person, 8h per day
Care of accompanying persons

Cash flow availability:*

Yes
No

If yes amount*

VIP reception at the airport:*

Yes
No

VIP reception

If yes how many persons*

Airport*

Date*

Time*

:
HH

MM

Flight number*

Arrival destination*

Hospital
Hotel