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In order for us to respond to your enquiry as quickly as possible, please complete the form below.
Please note that obtaining a VISA is subject to proof of hospitalisation abroad and prior payment for treatment. Admission agreement from the hospital and proof of payment will only be provided upon receipt of funds.

Preamble :

I am filling out this application for myself

Yes

If no, please specify your relationship with the patient

What is the reason of your request ?

Personal information

Patient nationality:

Name*

First name*

Sex

Female

Male

Birth date*

Phone

Email*

Are you covered by the French social security system ?

Yes

Do you have private insurance ?

Yes

If yes, please precise

Are you already in France ?

Yes

If yes, please specify your location and return dates

Medical information :

Nature of pathology :

Please specify your request (needs, medical history, requirements…):

To my knowledge, I attest to the accuracy of this information. In case of changes in my state of health and / or my medical prescriptions, I will inform the practitioner who is treating me at the following appointment. **

By submitting this form, I agree that the data entered will be processed by the ELSAN’s International Patient Office in order to be contacted, so that a proposal for treatment in one of the Group's facilities and an associated estimate can be sent to me.*

By submitting this form, I agree that the information entered in it will be used to allow a personalized study to be carried out and to ensure the proper processing of my requests.*

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ELSAN
58 bis rue la Boétie - 75008 Paris
+33 1 58 56 16 80

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