Nous contacter

You are

Patient
Doctors
Education & Residency

Requested Service

In-Hospital consultation, check-up, or surgery
Remote video appointment
Written Second Opinion
Imaging written conclusion
Pathology written conclusion
Other

Name*

Prénom

Surname*

Nom

Medical insurer, if present

What is your citizenship/ nationality?

Please summerize your request

Do you live in Italy?

No
Yes

What is your country of permanent residence?

Dates of arrival to Italy

Attach documentation attesting your medical history

Taille max. des fichiers : 10 MB.

Attach documentation attesting your medical history*

Taille max. des fichiers : 10 MB.

Attach your ID

Taille max. des fichiers : 10 MB.

Phone*

Email*

How would you like to be contacted?*

By phone
By email

Notes: The medical documentation must be presented in English, Italian or Russian and will allow Humanitas specialists to make an informed evaluation of your clinical case and offer the most appropriate treatment plan.

Information on the processing of personal data*

Read the Information on the processing of personal data*

I give my specific consent to the processing of my personal data.*

I give my specific consent to the processing of my data in order to receive communications and materials specific to my areas of interest in health care.

Untitled

First Choice
Second Choice
Third Choice

Contact Form EN