Dear patient, dear requestor,

In order to evaluate if we can offer a reasonable treatment option and to prepare an individual treatment plan, the medical specialists of " Health Travels Europe " require some information and medical data. Please note that we cannot deal with your inquiry unless you provide us this form completed in German or English and the necessary up-to-date medical reports in English (please provide Arabic documents only translated in English or German):

Please complete this Form in German or English ( required fields are marked with * )

Please note: Patients with a European Health Insurance Card / S2 form only need to fill out this form if treatment by physician of choice is desired.
I am requesting a copy of this inquiry form, including medical data.

Note on data privacy protection: Health Travels Europe will transfer the data without using any special technological encryption to the supplied email address. By requesting a copy, I am consenting to the transfer of medical data and I am also consenting to the further email communication without any special data encryption for subsequent correspondence (for example: issuance of cost estimate and treatment offer). In case I am not the patient myself, I confirm that I have the patient's permission to request this copy via unencrypted email and to consent to the further related correspondence to be sent via unencrypted email.
I agree that the data and documents I uploaded via this telemedicine portal will be saved for nine months. In case of a subsequent treatment or consultation by Health Travels Europe I furthermore agree that the data and documents will be saved in my personal patient file according to the German national legal requirements. In case I do not decide in favor of a treatment or consultation by Health Travels Europe all data and documents will be deleted automatically and irrevocably after nine months.
After the form has been sent, you will receive a confirmation to the specified email address with an upload link, which you can use to transmit other documents/images directly into the electronic patient record that has been created once the form has been sent. In case you wish to send us more information after you have submitted your documents, please send it by email.

Please do not fill out the form a second time in order to send us more documents or information. Your data has reliably reached us, if you received both of the automatic confirmation emails after submitting the form and the documents.
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Health Travels Europe
Health Travels Europe
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Tel. 0049 - 9621 - .1784080

Fax. 0049 - 9621 - 1793330

Montag - Freitag  09.00 a.m  -  04.00 p.m.
Saturday             09.00 a.m. -  12.00 a.m.