Request a treatment

Briefly give us an idea of the medications that you have been taking if any.

You just completed the medical information form. Please check your data below and confirm the form by clicking the button on the bottom of this screen. Your data will be send to our patient advisor who will prepare it for screening by our medical staff. You will be contacted by our patient advisor in the next couple of days. We will not pass on your data.

Please note, that the evaluation is done personally from our medical specialists. The doctor evaluate all your medical reports carefully. This complicated and important process costs our doctors and administration team much time and effort. So our professional evaluation and sending you a detailed cost estimate costs 100 EUR. The doctors will start to evaluate your reports immediately after the payment is done!

Beneficiary: Albairaq GmbH

Bank: Stadtsparkasse Haan

Bank address: Kaiserstraße 37, 42781 Haan

Account Number (KTO): 91315150

Bank Number (BLZ): 30351220

IBAN: .DE42303512200091315150

BIC: WELADED1HAA

Reference: Evaluation for Patient Name, Surname, D.O.B