IMT Telemedicine Form

Fill the form below to request an online telemedicine consultation at any of our partner hospitals.

Appointment Details

Appointment Details

Choose preferred country

Choose preferred hospital

Medical condition

Specialty

Preferred appointment date

Patient Details

Patient Details

Full name (as on passport)

Gender

Date of birth

Email address

Phone number (include country code)

Nationality

By clicking submit you agree to allow us to share your information with the specialists at the partner hospital you chose and you agree to our Terms of Use and Privacy Policy.

1 2

Back Next