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*:
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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 checks 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:

 
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