Represented Patient Registration

iMER

Patient Registration by Legal Guardian

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Represented Patient Registration

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Submission Date(Required)

DD slash MM slash YYYY

Patient Information

Full Name(Required)

First Last

Civil ID or Passport No.(Required)

Identification Type(Required)

Civil ID

Passport

Issuing Country(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Address Information(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Legal Guardian

Full Name(Required)

First Last

Civil ID or Passport No.(Required)

Identification Type(Required)

Civil ID

Passport

Issuing Country(Required)

Telephone(Required)

Email

Signature

Secondary Guardian

Please check "Yes" if you need to include a secondary legal guardian.

Yes

No

Secondary Legal Guardian

Full Name(Required)

First Last

Civil ID or Passport No.(Required)

Identification Type(Required)

Civil ID

Passport

Issuing Country(Required)

Telephone(Required)

Email

Signature

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 Type(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

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Private Medical Insurance

Please check this box if the patient has an active private health insurance plan.

Insurance Company Name(Required)

Insurance Plan Policy Number(Required)

Excluded Hospital / Medical Information

If yous wish to exclude specific medical information from a specific hospital, please state below.

Name of Hospital

Specific Medical Information to be Excluded