Request an appointment (International)

If you are a U.S. resident, please go to appointment information.

All fields are required unless marked optional.

Patient Insurance Information

Does the patient have health insurance?

Yes
No
Don't know

Primary insurance provider:

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Insurance policy/ID number:

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Insurance plan name:

(optional)

Name of the company that manages its insurance in the United States:

(optional)

Medical Concern

What is the primary medical problem or diagnosis for the appointment request:

In the process of scheduling an appointment, you may be asked to send a recent medical summary in English including diagnosis, pathology reports and local physician's treatment plan. We will contact you regarding when and how to send this information. Please do not send X-ray films.

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Appointment Information

Please plan on five to eight business days to complete your appointments.

Appointment date first choice:

Appointment date second choice from:

to(optional)

Referral Information

Did a physician refer you to Mayo Clinic?

Yes
No

First Name:

Last Name:

Country: