YOUR APPLICATION

You wish to take advantage of our services to organize your medical stay in France: with SOYUZ MED it’s quite simple and swift. To do that, you simply have to fill out the questionnaire herebelow, which will enable us to establish a price quote, FREE OF CHARGE. As soon as we will have received your request, SOYUZ MED will forward within 48 hours the possibilities of organization of your medical stay, along with a price quote.

Once you will have studied and approved this proposal (through fax, email or telephone), SOYUZ MED pledges to communicate to you within a week, the dates of your appointments, the names of your doctors, the address of the hospital as well as information about the other services you may have requested.

To make this possible, please fill out and send us the following questionnaire:

PATIENT IDENTITY

Mister / Mrs / Miss / Child
Last Name:
First Name:
Date of birth: / /
Adress :
Country :
Phone :
Fax :
Email :
Authorization for access to my medical file : Yes No
Is the illness known ? No
Yes, Si oui :
Do you have a file at Soyuz Med : Yes No

 

DESIRED SERVICES

Health Assessment : Yes No
Consultations :
Specialties
 
Paraclinical Exams : Lab Exams
Radiography ou Ultra Sound Scan
I.R.M. or Scanner
Endoscopy
Hospitalization:
Spécialties
Reeducation : Yes No
Desired Region : Paris / Marseille / Nice
Desired dates of stay: - - au - -

 

CONTACT PERSON (or Guardian)

Mister / Mrs / Miss
Last name :
First name :
Fax :
Email :
Telephone of the contact person :

 

OTHER SERVICES

Accompanying MD: : Yes No
Interpreter : Yes No
Car with chauffeur : Yes No
Hôtel : Yes No
  stars persons
Tourist Visit : Yes No

....................................................................................
CONDITIONS D’ORGANISATION :
As soon as you will have studied and approved the priced proposal (through fax, email or telephone), SOYUZ MED pledges to send you, within a week, the dates of your appointments, the names of your doctors, the address of the hospital, as well as any information about the other services you may have requested.

Tariff here