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International Patient Intake Form

Thank you again for selecting us as your provider of choice. Please complete this form accurately to ensure that we tailor your unique needs to the best treatment and care. If you need help or have questions, call 8006969 (if inside the UAE) or +971 2 419 4866 (if outside the UAE) or email internationalpatients@m42.ae

  • Step 1

    Patient Information

  • Step 2

    Referring Physician Information

  • Step 3

    Payment & Other Info

  • Step 4


  • Patient Information

    File format to be PDF, JPEG or PNG of less than 5MB

    Please note that medical report or diagnostic tests should be less than six (6) months old. File format to be PDF, JPEG or PNG of less than 5MB

    Emergency Contact Information: (Someone to Notify in Case of Emergency)


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