Appointment Request for International / Foreign Patients

Please read carefully before submission:

1. All fields are mandatory.

2. For New Patients: After submitting the form, email the following documents to genomee@neotiahealthcare.com:

   • Previous medical reports

   • A clear soft copy of the patient's passport

3. For Returning Patients:After submitting the form, email the following documents to genomee@neotiahealthcare.com:

   • Genome medical reports (with Registration Number)

   • A clear soft copy of the patient's passport

4. For All Patients:Please also include a clear soft copy of the attendant’s passport, if applicable.

Details of the Patient

Surname*

Given Name*

Gender *

Date of Birth *

Nationality*

Passport No*

Address in Native Country *

Address in India *

State *

City / District *

Pin Code *

Contact Number (In Native Country) *

Contact Number (in India)

Email ID *

Details of the Treatment

Diagnosis/Proposed Treatment*

Name of Doctor*

Department (Speciality)*

Cost of Treatment (Rs.)*

Duration of Treatment in Hospital (days)*

Tentative duration of stay in Hospital (days)