Medical Questionnaire

Request

title

Academic Title

Patient’s first name

Patient’s last name

Gender

Date of birth

Mothertongue

Nationality

E-Mail

City

Phone

Fax

Have you previously been a patient at the UKE?

What is your diagnosis and what symptoms do you experience?

Do you already have medical reports or test results from other hospitals that you can send us?

You can send us a file here.

I will send copies of my medical reports by mail.

Do you already have contact with a physician at the UKE? If so, whom?

Other information

How did you learn about us?

Privacy Policy

I accept the <a href="/contact/gdpr.html">Privacy Policy</a>

Don't fill this field!

Subpages

In cooperation with

Lufthansa

We are certified

Audit Familie Zertifikat

Diocert Siegel