Make an inquiry

Should you wish a medical examination or treatment, we kindly ask you complete the form below and forward it to our office by pressing "Submit" button. Please note all fields marked with asterisks (*) are required.

You can also forward the request via fax +49 761 270 19310 or 270 84060 or via e-mail info-ims@uniklinik-freiburg.de.

Should you wish information regarding Fields of Study and Courses, please contact the International Office of the Albert-Ludwigs-Universität Freiburg directly: io@uni-freiburg.de

* Patient’s first name, surname
*

* Patient’s date of birth
*

Gender
Male Female

* Country of residence
*

Telephone number (country code + area code)
*

Fax number (country code + area code)

* E-mail address
*

Contact person

Do you need visa support ?
yes no

Medical history

* What kind of treatment are you seeking?
*

What specialist would you like to have an appointment with?

* Preferred date of consultation
*

* How did you find our hospital?
Internet
friends/relatives
previous patients
newspaper/magazine
exhibition
travel agency
your physician
business partner
Other:

Further information, special requests

See also:

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