Treatment Inquiry & Appointment

Dear patient, dear requestor,

please note that we cannot deal with your inquiry unless you provide us with this form completed in English, German, Russian or Arabic and the necessary medical reports in English or German only.

Please complete this form in English, German, Russian or Arabic.

Kontaktformular/contact form/контактный формуляр

Patient Data

Medical Information

 

2. Copies of the required medical documents (no originals, no zip-, rar-, or bitmap-files)
I accept, that my data will be collected, processed, and used to enable the University Hospital Frankfurt to offer its services regarding my request.

Your personal data will also be collected, processed, and used on servers of our partner:
unimed Abrechnungsservice für Kliniken und Chefärzte GmbH
Michael-Uwer-Straße 17-19
66687 Noswendel
Telefon: +49 (0) 6871 / 9000-0
Telefax: +49 (0) 6871 / 9000-90
E-Mail: klinikservice@unimed.de
(out of University Clinic Frankfurt)*

In the event of cancellation, your data will be deleted upon receipt of your notice.
In case of denial (choosing “No”), the University Hospital cannot guarantee to reply to your request.
* Pflichtfeld