International Patient Intake Form

Announcement

18 Feb 2025

M42’s Healthpoint expands its plastic and reconstructive surgery offering with multidisciplinary care for specialized medical disorders

Learn More

Thank you for considering one of our state-of-the-art facilities for your care, including:

Please complete the International Patient Intake form below to help us tailor our services to your needs.

Patient Information

Request No. (issued to you by our International Patients team) *

Date of Birth *

Gender *

Male

Female

Nationality *

Country of Residence *

Home Address

Upload Passport *

Drag & drop here or Browse

File format to be PDF, JPEG or PNG of less than 5MB

Upload Medical Report

Drag & drop here or Browse

Please note that medical report or diagnostic tests should be less than six (6) months old. File format to be PDF, JPEG or PNG of less than 5MB

Are you taking any medication(s)?

Yes

Name

Dose

Other Frequency

Name

Dose

Other Frequency

Name

Dose

Other Frequency

Other Medications

Other preferred language for medical care *

Other Spiritual Belief *

Name

Relationship

Mobile Number