Patient Enquiry Form

Submit your details down below and answer to the best of your abilities. Our coordination team will review your case and will be in contact with you shortly. If we think you have a great match, we would connect you with our suitable clinics.

SECTION 1: Contact Details

First Name

Last Name

Phone *

Email *

Preferred Contact Method

Please Select a Method

SECTION 2: Treatment Information

What Treatment are you considering? *

Please Select an option

If "Other", please specify

Describe what you are looking for *

Have you had a consultation in the UK?

Yes

If yes, what was recommended in that consultation?

SECTION 3: Budget & Timeline

What is your budget range (in USD)?

Please enter your budgeting range

When are you hoping to get a treatment? *

Please enter when you are expecting to get a treatment

SECTION 4: Medical & Travel

Do you have any medical conditions that we should be aware about? *

Will you be travelling with a companion or not?

No, just by myself

Yes, just with 1 person

Yes, with 2+ people

Do you need help with travelling arrangements?

Yes

Need some time to think about it

If yes, describe what are your travelling requirements?

SECTION 5: Consent & Compliance (CRITICAL)

Please check that you understand: *

I understand Amica International Services provides coordination only, not medical advice

I understand all medical decisions are made between me and the overseas clinic

I understand facilitation fees may apply as explained on the website

I consent to Amica International Services contacting me about my enquiry

I have read the Privacy Policy and Terms of Service

By checking this box, I consent to receive non-marketing text messages from Amica International Services about Healthcare programs and travelling expenses offers. Message frequency varies, message & data rates may apply. Text HELP for assistance, reply STOP to opt out.

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