APPLICATION FORM

Get a Quote

The following form will allow us to provide you with an initial quote for having medical treatment abroad.
Please provide as much information and detail as possible to enable us to give you an accurate quote.

Full Name: (required)

Email Address: (required)

Date of birth: (required)

Home Address: (required)

Postcode: (required)

Phone Number: (required)

When is it most convenient to contact you?

What type of treatment are you seeking information on?
Knee replacementHip replacementHeart careDental treatmentCosmetic surgeryOther

Please provide additional information on the treatment selected above to help us assess your requirements: (required)

Please let us know if you suffer from any of the following:
High blood pressureDiabetesHeart problems

When would you like to have your treatment?

Please select the additional services you would us to organise for you:
FlightsVisa (if required)AccommodationRecuperation holiday

Will you be accompanied by a relative or a friend? (required)
YESNO

Where did you hear about The Medical Tourist Company? (Optional)
Privatehealth / Treatment Abroad websiteInternetMagazine / NewspaperTelevision / RadioFamily or friendOther

Do you have any other questions or comments?

Attach the related documents: (MAX SIZE: 1MG)
File1:
File2:
File3:
File4:
File5:

Please tick the box to confirm that you have read and agreed to our Terms and Conditions