MediConta GmbH
Sulzbacherstr. 12 
80803 Munich

+49 176 2431 4511 (German, Russian)
+49 176 8107 1652 (German, English)
+49 89 5896 3519 (German, Russian)
Fax: +49 89 3706 0500

Commercial Register: HRB 152134 county court Munich, Germany
VAT Identification No.: DE 235057528

Treatment application
  1. For correct registration of the application it is necessary to fill the questionnaire given below, to provide medical actual information, and also copies of passports of the Client/patient and accompanying persons. Fields in the questionnaire, obligatory for filling are marked by an asterisk. If given sections are not filled in, the application is not processed. We pay your attention that we ask you to send scanned/copied epicrisis and medical records, instead of epicrisis/records in reprinted way since the patient can omit important medical data necessary for doctors to work out the Program of treatment.
  2. First, patronymic and last name of the patient(*)
    Please type your full name.
  3. Date of birth (day/month/year)(*)
    Invalid Input
  4. First, patronymic and last name of the contact person(*)
    Invalid Input
  5. Patient's address(*)
    Invalid Input
  6. Phone (*)
    Invalid Input
  7. Fax
    Invalid Input
  8. E-mail(*)
    Invalid email address.
  9. Diagnosis of the patient - (we ask to specify also associated diseases)(*)
    Invalid Input
  10. Assumed period of treatment
    Invalid Input
  11. Attached medical documents
    Invalid Input
  12. Special wishes
    Invalid Input