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Consultation request

Send us your file: our partner hospitals will review it and send you a costed opinion.

This form collects your preliminary administrative and medical information. It is neither a diagnosis, a prescription nor a medical opinion: your file will be passed to a specialist doctor or a partner hospital for assessment.

  • Secure payment
  • Reply within 48 hours
  • Support in French and English
  • Medical visa
  • 24/7 assistance
  • Africa → India support

The information you provide is strictly confidential and is shared only with the medical teams handling your file.

1. Personal details
Sex
Marital status
2. Contact details
3. Main reason for the request
How long have you had it?
4. Current symptoms
Symptom intensity
Are the symptoms constant or occasional?
5. Previous diagnosis or opinion
Have you already seen a doctor about this?
6. Tests already carried out

Attach the available results in section 14.

Tests carried out
Are the medical reports available?
Are the medical images available?
7. Medical history
Have you suffered from, or are you monitored for:
8. Previous surgery
Have you had surgery before?
9. Allergies
Do you have any known allergies?
If so, of what kind?
10. Medicines currently taken
MedicineDosageFrequencySince when?
11. Habits and further information
Do you smoke?
Do you drink alcohol regularly?
Do you have dietary restrictions?
12. What you are looking for
What kind of care are you looking for?
Have you already identified a specialty?
13. Preferences for your care
Approximate budget available for treatment
Will you be accompanied?
14. Documents to provide

Reports, imaging, lab results. PDF or images, 10 MB maximum per file.

15. Authorisation to share the medical file

I authorise the agency to pass the medical information and documents I have voluntarily provided to partner doctors, specialists and hospitals, solely in order to obtain a medical assessment, a second opinion, a preliminary cost estimate and/or a treatment proposal. I understand that the agency makes no diagnosis, and that any decision regarding my diagnosis, treatment, hospitalisation or possible surgery rests solely with the doctor or hospital that has examined me.

The information provided is self-declared. Any medical assessment, diagnosis, treatment recommendation, final cost estimate and treatment decision must be made by a duly authorised health professional or medical institution.