PLEASE, FILL OUT THE APPLICATION FORM, PROVIDING AS MUCH INFORMATION AS POSSIBLE TO HELP US ASSESS YOUR CASE BETTER.

INFORMATION ABOUT PATIENT

Day / month / year

COMMUNICATION

NB! Please be informed that we undertake to respond to your application within 48 hours. If you haven`t received reply e-mail from us within defined 2 business days, please check your spam and junk mail folders as well as “promotions” tab, if you are using gmail account.

I am informed that e-mail/telephone number provided in this Application Form will be henceforward used as the only official means of exchanging data and information with the clinic.

CURRENT MEDICAL ILLNESS

To start case assessment fill out additional medical information

RECEIVED TREATMENT

CURRENT / PLANNED TREATMENT

GENERAL CONDITION

OTHER RELEVANT ILLNESSES


Please, send the following documents to clinic@amberlifeclinic.eu

  • Medical report (epicrisis), histopathological, cytological findings etc.
  • Current (not older than 2 weeks) full blood count + WBC and the latest biochemical analysis (ALT, creatinine etc.)
  • Radiological findings (CT, MRI etc.). Images not necessary.

Maximum upload size per email: 20 MB
If medical report and radiological findings are not in English or Russian, please, upload and send a translation as well.


Any other relevant external links, to your medical files. (URL)

YOUR QUESTIONS / COMMENTS / OTHER RELEVANT INFORMATION YOU WOULD LIKE TO SHARE

I am informed that the permission to use my data may be revoked at any time, and that data submitted through the Application Form may be changed, corrected or deleted based on my written e-mail request sent to clinic@amberlifeclinic.eu

THANK YOU FOR YOUR TIME!

Amber Life Cancer Clinic

Responsible service: Patient service
Language for communication: LAT, RUS, ENG
Address: ​Jauna str.12, Jurmala, LV-2015, Latvia, EU
Phone: +371 67 229 522
Website: www.amberlifeclinic.eu
E-mail: clinic@amberlifeclinic.eu