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

Do you have health insurance? If yes, Name

What type of Medical Procedure are you interested in? (Please provide specific details so we can forward your request to the proper healthcare provider.) *

Upload Medical Record

please provide recent medical record or examination

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