Ladisten Clinic™ International Services Request

Please include your working EMAIL for us to be able to contact you. If you do not wish to complete this form, you may go back to the page you were on previously.

Fields marked with an * are required.

Patient Information

Have you previously been a patient at Ladisten Clinic? no yes 
Ladisten Clinic number:

Title:
Patient name (please list name as it appears on passport):

Last Name*:

First Name*:

Middle Name*:

Date of Birth: / / (month/day/year)

Patient's gender: *  male female

Parent/Guardian Name (if patient is under age 18):

Patient address*:

City*:

Province/Dept*:

Postal code*:

Country*:

Phone*:

Mobile phone:

Fax:

E-Mail:

Patient's primary language:

Please note: If English is not your primary language, we strongly suggest use of a Ladisten Clinic interpreter.

Interpreter Needed: no yes
Language:

Will you need assistance in obtaining a visa to Ukraine?:  no yes

Diagnosis(please be specific):

Your comment about desired procedures and treatment:

Appointment date requested:

First choice: / / (month/day/year)

Second choice: / / (month/day/year)

Appointment type requested:
 Consultation & Evaluation Surgery Rehabilitation

Please note: We may ask to send a recent medical summary in English including diagnosis, pathology reports, and local physician's treatment plan. We will contact you regarding when and how to send this information. Please do not send x-ray films via mail.

Referring Person Information

Referring person's name: (if applicable):

Relationship to patient::

Address:

City:

Province/Dept:

Postal code:

Country:

Phone:

Mobile phone:

Fax:

E-Mail: