Name *Date of Birth *Where do you live? *Gender *MaleFemaleIntersexEmail Address *Phone Number *HeightWeightLanguage *Please list any current medications0 / 180Do you drink alcohol or smoke tobacco? *Yes or NoYesNoList any current medical problems & allergies0 / 180List any past surgeries0 / 180What type of Medical Procedure are you interested in? *What is the destination of your choice for your Medical Procedure? *By submitting this form, I authorize Universal Medical Travel to share my health information with partnered hospitals, clinics, and providers for medical treatment or consultation. I can revoke this consent anytime by notifying them 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 *AgreeSubmit Information