Mandatory Preregistration Form

Thank you for choosing Mediclinic Middle East.

To request a telemedicine consultation with one of our Doctors please fill in the information below:

First & Last Name

Gender

Date of birth

Mobile Number

Email ID

Emirates ID or Passport number

Insurance Provider Name, Policy Number and Expiry date

Nationality

City

Area

Full name

Relationship

Mobile number

Agree for the Account settlement & treatment responsibility & consent form This field is required.

Please don't fill out this field if you are a human being*

This field is required.