Kontaktformular/contact form/контактный формуляр

Treatment Inquiry & Appointment

Dear patient, dear requestor,

please note that we cannot deal with your inquiry unless you provide us with this form completed in English, German, Russian or Arabic and the necessary medical reports in English or German only.

Please complete this form in English, German, Russian or Arabic.

Current information

Due to the current situation around the "Coronavirus SARS-CoV-2" there are also restrictions in the area of the International Office. Unfortunately, we are currently unable to offer any treatment for patients who are in countries classified by the Robert Koch Institute as so-called "risk areas".

Kontaktformular/contact form/контактный формуляр

Patient Data

Please select

Title

First name*

Last name*

Gender*

Date of birth (dd.mm.yyyy)*

Address*

Zip code or city*

Country*

Phone

Fax

E-Mail*

Contact person (if different from patient)

Medical Information

1. Disease(s) / Symptome(s) to be treated*

I accept, that my data will be collected, processed, and used to enable the University Hospital Frankfurt to offer its services regarding my request.

Your personal data will also be collected, processed, and used on servers of our partner:
unimed Abrechnungsservice für Kliniken und Chefärzte GmbH
Michael-Uwer-Straße 17-19
66687 Noswendel
Telefon: +49 (0) 6871 / 9000-0
Telefax: +49 (0) 6871 / 9000-90
E-Mail: klinikservice@unimed.de
(out of University Clinic Frankfurt)*

In the event of cancellation, your data will be deleted upon receipt of your notice.
In case of denial (choosing “No”), the University Hospital cannot guarantee to reply to your request.

Data protection*

I agree to the Data protection agreement and agree to the processing of my personal data.

Kontaktformular/contact form/контактный формуляр

Adresse

Kontakt

Lob- und Beschwerdemanagement

Treatment Inquiry & Appointment

Kontaktformular/contact form/контактный формуляр