نموذج المعلومات الطبية

Briefly give us an idea of the medications that you have been taking if any.

You just completed the A1 medical information form. Please check your data below and confirm the form by clicking the button on the bottom of this screen. Your data will be send to our patient advisor who will prepare it for screening by our medical staff. You will be contacted by our patient advisor in the next couple of days. We will not pass on your data.

Please note, that the evaluation is done personally from our medical specialists. The doctor evaluate all your medical reports carefully. This complicated and important process costs our doctors and administration team much time and effort. So our professional evaluation and sending you a detailed cost estimate costs 70 EUR. The doctors will start to evaluate your reports immediately after the payment is done!

Получатель / Beneficiary: A1 Medical Services

Банк / Bank: Commerzbank AG

Адрес банка/ Bank address: Markt 21-25, 41460 Neuss, Germany

Номер счета / Account Number (KTO): 754741700

Номер банка / Bank Number (BLZ): 30040000

ИБАН / IBAN: DE38300400000754741700

БИК / BIC: COBADEFF300

Назначение платежа/ Reference: Evaluation for Patient Name, Surname, D.O.B