Contact Checkup

Your Title*
Mr.Mrs.Ms.

First name*

Last name*

 
Date of Birth - Format: DD/MM/YYYY *(required)

Your City*

Choose the country you're from*:
AlbaniaAlgeriaAndorraAngolaAntigua & BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBhutanBoliviaBosnia & HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCentral African RepublicChileChinaColombiaComorosCongoCongo Democratic RepublicCosta RicaCote d'IvoireCroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEast TimorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaFijiFinlandFranceGambiaGeorgiaGermanyGhanaGreeceGrenadaGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiKorea NorthKorea SouthKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalThe NetherlandsNew ZealandNicaraguaNorwayOmanPakistanPalauPalestinaPanamaPapua New GuineaParaguayPeruThe PhilippinesPolandPortugalQatarRomaniaRussiaRwandaSt. Kitts & NevisSt. LuciaSt. Vincent & The GrenadinesSamoaSan MarinoSao Tome & PrincipeSaudi ArabiaSerbiaSeychellesSingaporeSlovakiaSloveniaSolomon IslandsSouth AfricaSpainSri LankaSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTunisiaTurkeyTurkmenistanUkraineUnited Arab EmiratesUnited KingdomUnited States of AmericaUruguayUzbekistanVatican City (Holy See)VenezuelaVietnamYemenZambiaZimbabwe

Your Mobile number with country code*

Your Email*

 
For whom?*
MyselfRelativeFriendOther

 
What checkup you like to book?*
Basic General Checkup (Starts at 1.700 €)Premium Checkup (Starts at 3.100 €)

 
Which additionally appointments you like to book?*

NoneDermatologyDental checkupEye checkupGynecologyIVF TreatmentNeurologyOrthopedicsRadiology (MRI/CT/PET)Thyroid glandsUrologyVascularAny other not listed here

 
Choose the country you want to get the checkup*
GermanyAustriaCzech RepublicSwitzerland

 
How you would like to cover the treatment cost?:*
Self-paying (No insurance)International Health InsuranceEmbassy / MOHGerman National Health Insurance

 
Explain your medical problem / medical needs:

 
Attach files here:
Max. upload per file 3MB per file (jpg, jpeg, doc, docx, pdf) only
 

I agree to the Privacy Policy and Data Usage Policy of GermanyHealth*.