جدولة مواعيد المرضى الدوليين

طلب موعد

نشكرك على اهتمامك بـمستشفى ماس جنرال بريغهام لتوفير احتياجاتك من الرعاية الصحية. لمساعدتك على أفضل وجه، يُرجى إكمال النموذج أدناه ليتواصل معك أحد أعضاء فريق خدمات المرضى الدوليين في أقرب وقت ممكن. ملحوظة: قد تظهر بعض أسئلة هذا النموذج أو تختفي بناءً على إجاباتك.

*تشير إلى خانة مطلوبة.

I am seeking care for?

Primary Contact

If you are completing the form for someone else, please include patient's primary contact's information below.

Contact Relationship

Preferred Title

First Name

Last Name

Phone Number

Country and City Code

Email Address

Patient Information

This form is intended for international patients. If you reside permanently in the United States, learn more about being a patient here.

Have you ever been a patient at any of the Mass General Brigham Hospitals?

Mass General Brigham Patient Medical Record Number

Preferred Title

First Name

Middle Initial

Last Name

Gender

Date of Birth

Day

Month

Year

Patient Information, Continued

Is the patient 18 or older?

Parent/Legal Guardian First Name

Parent/Legal Guardian Last Name

Parent/Legal Guardian Day of Birth

Parent Legal Guardian Month of Birth

Parent/Legal Guardian Year of Birth

International Permanent Address

This form is intended for international patients. If you reside permanently in the United States, learn more about being a patient here.

Mobile Phone

Country and City Code

Home Phone

Country and City Code

Email Address

Street (including Apt/House/Block #)

City

Province/Region (optional)

Postal Code

Country

Reason for Requested Visit/Clinical Diagnosis

Will you require an interpreter?

What is your primary language?

Do you require assistance with a visa letter for this appointment?

Please note: to visit the US for medical care, you may need to obtain a nonimmigrant visa (B-2). Documented proof of sufficient funds may be required to cover all costs related to your travel, in addition to hospital and physician fees. Please visit Visitor Visa (state.gov) for detailed visa requirements.

Additional Details

Preferred Travel Dates

Preferred Travel Start Date

Preferred Travel End Date

Please indicate your primary coverage?

Self PayInsuranceGovernment

How did you hear about us? Select all that apply.

Please provide the referring physician's name.

Please provide.