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Information Request Form

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If you have a medical question for our Clinic, feel free to fill out and submit the form below. This service is offered to you free-of-charge. You will receive an answer by email, so make sure you've entered a valid email address.

 

Your Request
Subject*:
Message type:
Please reply     For your information
 
Priority:
Low     Normal     High
For Urgent matters, please call !
Imaging / X-rays uploads, type JPG, TIF, or PNG, size 20kB to 6 MB
Image 1:
 optional
Image 2:
 optional
Image 3:
 optional
Image 4:
 optional
Your Request*:
Patient Data
Gender*:
Male   Female
Firstname*:
Family name*:
Birth date*:
format: DD/MM/YYYY
Street:
House number:
ZIP Code:
City:
State:
Country*:
Telephone*:
Email*:
Email again*:
 type again, do not copy-paste
Verification code*:
   type-over anti-spam code

                            *) required fields

If you have problems using this form, or didn't receive an answer within 5 days, please contact the This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

 

 


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Contact Belgian Clinic

helpdeskFor international contact with our main office in Belgium, please use the information given below:

 

Contact Italian Clinic

For a direct contact with our Itailian Clinic at Rome, use the information given below: