MedSolutionan operating division of Medical Tourism Inc.

Patient Inquiry Form --

To inquire with MedSolution.com, please fill out and submit our contact form. A patient care coordinator will contact you, explain our process and address any questions you may have.

First Name: *
Last Name: *
Address:
City:
State/Province:
Country: *
Zip/Postal Code:
Phone Number: *
Email: *
When is the most convenient time to contact you?: *
Preferred method of contact: *
What type of treatment are you seeking information on?: *
IMPORTANT: Please specify a procedure
Any other information that would help us assess your requirements?:
When would you like to have treatment?: *
Country of Choice: *
If you selected 'Other':
How did you hear
about us?:
*
If you selected 'Other':
Do you have any other questions or comments?:
Security Code: Change Image
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Patient Inquiry Form