Please, fill up the below form the more accurate possible so we can forward this information to the doctors and specialist to assess your case. If you have questions about how to fill it up, contact us via phone (+34 952 368 146) or email: firstname.lastname@example.org and we will help you kindly.
If you have available updated medical information, with tests, reports and images, you can send them to us to assess better your case. Those files must be updated and the most recent possible.
This form does not compromise you to have a consultation with us, but it will help us to know if we can treat you with our therapies or other specialist’s therapies and therefore you may know if you case has a possible treatment.
COMPLETE THE FOLLOWING FORM AS ACCURATELY.