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  In order to assess your medical case thoroughly, we ask that you provide all information requested. A reply will be sent to you promptly, usually within 48 hours, depending on the details of your case.

Please note: A specialist in the required discipline will evaluate the information you provide. To enhance accuracy of the diagnosis/prognosis/second opinion, Please provide as many current details as possible on the form and include, in electronic form, any relevant reports from your physician(s) and any imaging (MRI, CT) and or test results you may have.

Thank you for helping IMS to serve you better.

Personal Information (Please fill in all of the required information)
 
Given (First) Name:*  
Surname:*  
Gender: *  
Birth Date: Day: Month: Year:
Country: *  
City:
Zip Code:
     

Contact Details

 
Home phone number:
Country code:
Area code:
Number:
Work phone number:
Country code:
Area code:
Number:
Extenstion:
Cell phone number :
Country code:
Area code:
Number:
FAX:
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Number:
Email: *  
 
The procedure you are interested in : *  
Comments or questions :
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PRIVACY STATEMENT : All information submitted to IMS is deemed confidential. Your data is deleted from our website server when received. Upon completion of this query, all copies are securely purged to insure patient privacy. If you have, any questions please feel free to contact our support center at your convenience. A confirmation e-mail will be sent to you shortly.

 
 
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