International Treatment Inquiry

Should you wish a medical examination or treatment, please provide us with this form completed in English and the necessary medical Report.

» Form in German / Formular in deutscher Sprache

Kontakt englisch (neu) / Selbstzahler

Patient data

Salutation*

Title

Name*

Surname*

Gender*

Date of birth*

Street / No.*

ZIP / City*

Country*

E-Mail*

Phone

Visa assistance

Do you require visa assistance? (invitation for the embassy)

Providing the information requested in the following two fields (Passport number and copy of the passport) is voluntary. However, as treatment can not be carried out at Klinikum Stuttgart without the data asked for in those two fields, we have marked them as mandatory. Reason is, that this information enables accurate identification and thus serves patient safety.

Number of passport*

Copy of Passport*

Contact data of requestor

Name requestor*

E-Mail*

Phone*

Sponsor / Name of insurance/embassy

Patient number / file number from insurance/embassy

Medical Information

Medical history / Diagnose*

What kind of treatment do you expect?*

Specialty departments

Do you (the Patient) have any infections at present?*

Do you (the Patient) have any open wounds at present?*

Please indicate your (the Patient's) mobility status*

not restricted

on a wheel chair

bed ridden

in intensive care

Was the Patient already treated at Klinikum Stuttgart?*

Please indicate treatment period (month/year) and CASE number, if known.

Additional information / your message

Desired appointment date

Medical Reports

Medical documents

Total size of documents may not exceed 50 MB.

DICOM

I will send DICOM files on CD-ROM/DVD via conventional mail.

Please select

I would like to request that you send me a copy of this contact form.

Please confirm*

You wish to communicate with us via e-mail. Please note: The transmission of data by e-mail and via the Internet is not a secure form of communication. There is a risk that your data could fall into the hands of third parties or be falsified. This may have adverse consequences for you under certain circumstances. If you wish to communicate with us in this way, it is therefore necessary that you give us your consent to this form of communication. By checking the box, you give us your consent to communicate via e-mail. Thank you for your understanding.

Please confirm*

I agree that the data and documents provided by me will be saved in my personal patient file in accordance with the legal provisions applicable in Germany, regardless of any consultation and / or treatment provided of Klinikum Stuttgart. All data and documents can be deleted after 10 years at the earliest. X-ray/CT/MRI images can be irrevocably deleted after 28 years at the earliest.

Security test ( mathematics task )

Bitte Rechenaufgabe lösen und das Ergebnis in das Feld eintragen.

You have problems to submit this form? Please check previous steps for missing mandatory information.

Bitte dieses Feld NICHT ausfüllen!