IAG DELIVERS FOR YOU!

Receive a Free Opinion and Price Quote for your procedure. We'll need your recent reports, and test results(if applicable). Once we have your vital information, your free opinion is usually available within 48-hours. Please provide the requested details so that our patient advocates can promptly reply with detailed information for your consideration.
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Name:		*
Address:		*
City:		*
State:		*
Zip Code:		*
Phone:		*
E-mail:		*
Best time(s) to call:
How did you hear of us?
Is this inquiry for yourself or on behalf of someone else?
	Myself
	Someone Else
	A Minor (Pediatric)
Patient's Age
	*
What sort of procedure(s) are you considering? (check all that apply)
	Bariatric Procedures
	Cardiac Procedures
	Cosmetic Procedures
	Orthopedic Procedures
	Pediatric Surgery
	Oncology Procedures
	Other
Why are you considering overseas treatment? (check all that apply)
	No insurance, self pay
	Access to lower cost care
	Access to high quality, personalized care
	Access to treatments not yet available here
	Ability to get treated more quickly
	Better options for convalescent care
	Anonymity
	Opportunity to couple treatment with a vacation
	Other
Do you have insurance?
	Yes
	No
	If yes, with which Carrier?
How urgent is your need?
	Immediate
	1-2 months
	3-5 months
	6+ months
Do you have a doctor who will help you obtain treatment overseas?
	Yes, I have a doctor
	No, I need a doctor
	No, I don't think I need a doctor
Have you discussed alternatives with a doctor?
	Yes
	No
Have you ever traveled outside North America?
	Yes, often
	Yes, a few times
	Yes, once
	No, never
	Do you and your traveling companion have passports?
	Yes, both do
	Patient Only
	Traveling Companion Only
How do you intend to pay for your treatment?
	Cash
	Credit
	Insurance reimbursement
	Other
	Don't know
Any other remarks or special requests:  (Optional)

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