Description of the disease
When do you plan to travel for treatment?
Briefly describe your problem and ask your questions - so that the doctor can develop a more relevant treatment program
How long do you plan to travel for treatment?
I do not wish to travel for treatmentWithin a month from nowfrom one to two monthsfrom two months to 6 monthsmore than 6 months
Please fill in the following information correctly to be contacted
Please fill in the patient's personal data,
name and nickname
country of residence