Contact form international patients

Patient details

Name *

First name *

Date of birth *

E-mail *

Phone *

Street *

Postcode/City *

Country *

Contact details (parents, partner)

Health insurance

Insurance class *

Private

Semi-private

General

Self-payer

Medical details

Request *

Confirmation by telephone (costs CHF 200.-)

Feedback by e-mail (costs CHF 125.-)

Appointment at our consultation at the Inselspital Bern, Switzerland (costs CHF 300.-)

Case presentation at an interdisciplinary board (costs CHF 500.-)

Other (Please describe your request)

Please describe your request

File upload

Please do not use any special characters or umlauts in file names.
The following file types are permitted: pdf, jpg, png, svg, bmp.

Medical report

Examination results/ findings

Further report

Imaging *

I will then send the imaging via data transfer ( wetransfer.com, swisstransfer.com).

I will send the imaging as a CD.

No imaging available.

Don't fill this field!