Patient Name *

Date of Birth *

Where do you live? *

Gender *MaleFemaleIntersex

Email Address *

Phone Number *

Height

Weight

Language *

Please list any current medications0 / 180

Do you drink alcohol or smoke tobacco? *

List any current medical problems & allergies0 / 180

List any past surgeries0 / 180

What type of Medical Procedure are you interested in? *

What is the destination of your choice for your Medical Procedure? *

What is your preferred date of travel? *

By submitting this form, I authorize Universal Medical Travel to share my protected health information with partnered hospitals, clinics, and healthcare providers for medical treatment or consultation. I can revoke this consent anytime by notifying Universal Medical Travel via email or in writing, without affecting prior actions. This consent remains valid until I revoke it. By checking the box, I confirm I have read and agree to these terms.

I Agree with the terms and Conditions *Agreed