Doctor Referral Form

Thank you for referring your patient through IMT. We want to make it easy for your patient to get treatment options and quality health care from our partner hospitals in the shortest time possible.

This brief form is to help us understand how we can best assist your patient and find them the right overseas medical treatment.

Kindly fill the form below with your patient’s correct information. This will enable the specialists/doctors at our partner hospitals to provide you with the correct feedback and right treatment options for your patient.

We thank you for trusting us to help provide the best service to your patient.

Doctor Referral Form

    Referring Doctor Information

    Patient Information

    Which Country(s) is the patient most interested in visiting for medical treatment?

    If you have medical reports or scans, please forward via email to [email protected] and include the patient's name in the subject.

    Disclaimer - Please tick each box before submitting
    You have confirmed with the patient to allow us to share their information and medical records with our suggested partner hospitals to get a treatment plan and costing
    Agree to our terms and Conditions (to read these please click here)