Create Requests | Al-Saleh

Treatment request form for patients abroad

Patient data

Patient's name (in Arabic) *

Patient's name (in English) *

Gender *

Age *

Place of Birth

State Birth Place *

City Birth Place *

Birth of Date *

Job *

Passport number *

Place of Issue *

Date of Issue *

Expiry Date *

Father's Job *

Mother's job *

Your residential address in Yemen

State *

City *

Neighbourhood/Street/Village *

Street *

Patient's phone number in Yemen *

Phone number of a relative in Yemen *

Relationship *

Relative's job *

The duration of his treatment in Yemen *

How did you find out about the project? *

as *

Residence and treatment abroad data

The country in which he is currently receiving treatment *

Date of entry into the country *

Residential address in the country *

Phone number in the country *

Phone Whatsapp *

Disease and treatment data

Type of Disease *

Hospital name *

Hospital Type *

as *

Hospital address *

Name of the attending physician *

Physician Address *

Physician Phone *

Physician Email *

Date of last medical examination *

Is there an entity that covers the treatment expenses? *

Yes

Organization Name *

PDF File Results of the latest tests *

PDF File Last Medical Report *

passport photo *

Image of the page containing the entry stamp *

PDF File Image of the embassy note with the donor's name and kinship *

PDF File of the embassy approval for kidney or liver transplant *

PDF File of the atomic scan result *