Minneapolis Health Clinic Concierge and Medical Tourism Services

Concierge And Medical Tourism Services Form

Select the type of service you want from Minneapolis Health Clinic. This gives you access to a yearly physical, referral services and access to a board certified internist when needed
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Patient Gender*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Patient E-Mail*
example@example.com
Patient Height (cm's)*
Patient Weight (kg's)*
Phone Number
Please enter a valid phone number.
What do you need assistance with ?*
Choose your subscription

Basic- $50/month or $500 per yearBasic Plus- $70/month or $800 per yearExecutive Access- $100/month or $1000 per year
Which geographical location would you like to be referred to?
Please check all that apply

United StatesUnited KingdomCanadaDubaiAccra-Ghana
When are you thinking of travelling. Please give us an approximate time for your trip.
Will you need a letter for the Embassy?
How are you paying for the medical services

Medical InsuranceSelf payOther
Explain if you are using other forms of payment
Will you need assistance with accommodation?
Upload any relevant information that will make us understand your situation better

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My signature below confirms that I assume financial responsibility of the services received from Minneapolis Health Clinic and will pay my medical bill in a timely manner. A secure link will be sent to you for payment after submitting the form.

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Concierge And Medical Tourism Services Form