Registration of foreign citizens for remote consultation, treatment or operation

Patient’s
data

Patient’s surname *

Patient’s name *

Patient’s patronymic

Date of birth*

Contact phone number *

E-mail*

Please note that we will follow up on your request by the e-mail you indicated.

Country *

Information for consultation

Have you previously received care at Bakulev Center?*

Yes

Purpose of consultation: *

Type of consultation:*

Remote consultation

Registration for treatment

Registration for operation

Documents are accepted for consideration in Russian.

Attach medical documents (PDF, JPG, PNG, ZIP)

Cardiologist’s extracts from the medical history (indicating the physical examination, complaints, anamnesis, concomitant diseases, prescriptions)

Echocardiogram protocol

ECG strips

Other medical document

Here you can provide the additional information about concomitant diseases:

The address of residence

Is the patient transportable? *

Yes

Are there any indications for surgery? *

Yes

Preferred date and time of consultation *

I consent to the processing of Personal data обработку Персональных данных and accept the Personal data processing Policy and the Terms of service *

I am not a robot

* — mandatory fields

Documents are accepted for consideration in Russian.

Attention!
Foreign patients must provide the following documents to the group of international scientific programmes support for the registration at the place of stay during hospitalization to A.N.Bakulev Center:

A copy of the foreign passport (a copy of all pages with marks);
A copy of the foreign passport of a planned accompanying person (a copy of all pages with marks);
A copy of the migration card;
A copy of the birth certificate (children under 18) and a copy of parent’s passport (of all pages with marks);
A copy of registration at the place of stay (if you have, for foreign citizens living in the RF);

Registration of foreign citizens for remote consultation, treatment or operation

Patient’s data

Information for consultation

Plan a visit to our Center

Patient’s
data