Cost Information

Please fill in this form so that we can send you a detailed and binding offer. Of course, Medical Escort Service International will execute the accounting exactly according to the services that you have applied for.

Hint:

In order to contact us, please turn to:

1. Mohamed Utaman phon Nr. 00218913753639 Tripoli-Libya 2. Eng. : A. M. Sallabi phon Nr. 00218925108944 Bngazi-Libya 3. Dr. Adel Mohamed phon Nr. 00218925004619 sebha-Libya 4. S. Milad Alfagi phon Nr. 00218925057534 Tripoli-Libya 5- M. Said M. phon Nr. 002187322766 or 002187322495 Bargen- Libya 6- Hamid phon Nr. 00218213350501 Sudan

* Code number:

Application form (for ambulatory and in-hospital therapy)

*Indicates a required field

Patient information
* Family Name
* Surname
Gender	Female Male
Birthday
Address
City
Postal Code (ZIP)
Federal State
Country
* eMail
Phone
Fax
* Number of passport
Patient's family status

Method of payment
Method of payment	Self-pay patient supported by Embassy

Indication of date

Have you already had contact to MEDICAL ESCORT SERVICE INTERNATIONAL?

	No
	Yes
	Treatment by Medical Escort Service International.

Kind of treatment

First examination Follow-up examination

Patient's proposal for appointment with a doctor (please state time frame)

Medical information

Medical relevant information

Acute troubles

Troubles

In addition to above information we ask you for transferrance.

Information on medical practitioner If necessary we can contact your medical practitioner for further information.
Name medical practitioner
Telefon medical practitioner
Fax medical practitioner
E-mail medical practitioner
Further remarks

Informaiton on references
How did you get to know MEDICAL ESCORT SERVICE INTERNATIONAL?	Other references ... please state =>