Patient Self Registration

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Submission Date(Required)

Patient Information

Full Name(Required)

Civil ID or Passport No.(Required)

Identification Type(Required)

Civil ID

Passport

Issuing Country(Required)

Date of Birth(Required)

Telephone(Required)

Address Information(Required)

Medical Questionnaire

Complaints and patient’s general condition at the present time(Required)

Medical history, present disease/complaints (shortly)(Required)

Other concurrent/related medical issues/diseases(Required)

Heredity associated with the underlying disease(Required)

Please, describe all hospitalizations and operations in chronological order

(in case of prolonged illness and treatment)

Please, describe all the treatments made in chronological order (preferably with all the necessary dates and doses)

(in case of prolonged illness and treatment)

Request/Goal(Required)

Online Consultation

Treatment/Examination

Other

Registration Fees

The registration fee for patients using iMER services is a fixed rate of €150. This fee covers the administrative processing of medical registration and applies to all patients, regardless of the registration method selected.

Payment Options(Required)

Bank Transfer

Online Payment

Bank Name: Eurobank
Beneficiary: iMER Medical Services Ltd
Account Number: 001-00002411
IBAN: CY42 0180 0008 0000 3001 0000 2411
SWIFT: ERBKCY2N

Please send deposit slip to iMER by fax or email.
Please remember to indicate the patient’s name as reference on the deposit slip.

Bank Name(Required)

Cheque Number(Required)

Open iMER Payments

Private Medical Insurance

Please check this box if you have an active private health insurance plan.

Insurance Company Name(Required)

Insurance Plan Policy Number(Required)

Patient Signature(Required)

Please provide your signature below