EAMN Medical Access Germany Patient Pre-Qualification & Medical Assessment Form

EAMN Medical Access Germany Patient Pre-Qualification & Medical Assessment Form

Pre-qualification and medical assessment for treatment in Germany. Please complete all sections using clear English. Refer to the original document for exact field wording, options, and numbering.
Personal Information
Title
First Name
Middle Name
Last Name
Date of Birth

MonthDayYear
Date
Age
Sex

Other
Nationality
Country of Residence
Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip CodeCountry
City
State/Province
Postal Code
Mobile Number with Country Code
Please enter a valid phone number.Format: (000) 00000000000.
WhatsApp Number
Please enter a valid phone number.Format: (000) 00000000000.
Email
example@example.com
Preferred Language
Marital Status

Other
Occupation
Employer
Emergency Contact
Full Name

First NameLast Name
Relationship
Telephone
Please enter a valid phone number.Format: (000) 00000000000.
Email
example@example.com
Country

Financial Information
Primary funding source
Estimated budget for medical travel (EUR)
Sponsor Details
Sponsor Full Name

First NameMiddle NameLast Name
Sponsor Phone Number
Please enter a valid phone number.Format: (000) 00000000000.
Sponsor Contact and Support Details

Accompanying Person
Accompanying Person Full Name

First NameMiddle NameLast Name
Relationship to Patient
Accompanying Person Phone Number
Please enter a valid phone number.Format: (000) 00000000000.
Religious/Cultural Requirements
Religious or cultural requirements

Other
Additional notes or special instructions
Document Uploads
Passport copy

Cancelof
Medical reports

Cancelof
Scans and imaging results

Cancelof
Health insurance document

Cancelof
Other supporting documents

Cancelof

Patient Declaration
I declare that the information provided in this form is true, complete, and accurate to the best of my knowledge.
I consent to the processing of my personal and medical data for the purpose of assessing my pre-qualification and medical access request, in accordance with applicable data protection laws.
I authorize the medical provider, its representatives, and relevant administrative partners to verify the information provided and to contact me or my healthcare providers if needed for assessment purposes.
Electronic Signature
Printed Name

First NameLast Name
Signature Date

MonthDayYear
Date
Electronic Signature
Should be Empty: