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Patient ID (if available)

Date of birth*

Phone*

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Please summarize your request

Medical insurer, if present

Attach documentation attesting your medical history

Max. file size: 256 MB.

Attach documentation attesting your medical history*

Max. file size: 256 MB.

Attach your ID

Max. file size: 256 MB.

Notes: The medical documentation must be presented in English, Italian or Russian and will allow Humanitas specialists to make an informed evaluation of your clinical case and offer the most appropriate treatment plan.

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