You can request a medical appointment by filling out the form below and clicking on SEND.

We will email you back the details for the first appointment.

All information is treated confidentially for exclusive use of the UOI.

Medical Form

Please provide the maximum amount of information

Entries marked with an asterisk (*) are mandatory

*Name:

*Surname:

*Age: yrs/old *Gender:

*Tel (Morning): *Tel (Evening):

*e-mail:

Diagnosis:

Medical History:

Allergies Cardiovascular Accidents Hypertiroidism

Diabetes Arterial Hypertension Cardiopathies

Diagnostic Tests:

X-Rays Magnetic Resonance T.A.C.

Write below any additional information you may consider to be important
and click on SEND: