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Mayo Clinic Representative Office in Middle East International Services Request

All fields are optional unless marked required.

Patient Information

Have you previously been a patient at Mayo Clinic?

Site of visit:

Jacksonville

Rochester

Arizona

Mayo Clinic number:

Mayo Clinic number: must have at least 0 and no more than 256 characters.The value of the Mayo Clinic number: field is not valid.

Title:

Last name:

(required)Please enter last name.Please enter last name.

First name:

(required)Please enter first name.Please enter first name.

Middle name:

Middle name: must have at least 0 and no more than 256 characters.The value of the Middle name: field is not valid.

Date of birth:

(month/day/year)Date of birth: must have at least 0 and no more than 256 characters.The value of the Date of birth: field is not valid.

Patient gender:

Male

Female

(required)

Parent or guardian name (if patient is under 18):

Parent or guardian name (if patient is under 18): must have at least 0 and no more than 256 characters.The value of the Parent or guardian name (if patient is under 18): field is not valid.

Patient address:

(required)Please enter the patient's address.Please enter the patient's address.

City:

(required)Please enter the patient's city.Please enter the patient's city.

Province/Dept:

(required)Please enter the patient's province/dept.Please enter the patient's province/dept.

Postal code:

(required)Please enter the patient's postal code.Please enter the patient's postal code.

Country:

(required)Please enter the patient's country.Please enter the patient's country.

Phone:

(required)Please enter the patient's phone.Please enter the patient's phone.

Mobile phone:

Mobile phone: must have at least 0 and no more than 256 characters.The value of the Mobile phone: field is not valid.

Fax:

Fax: must have at least 0 and no more than 256 characters.The value of the Fax: field is not valid.

E-mail:

Enter a valid email address.

Patient's primary language:

Please note: If English is not your primary language, we strongly encourage use of a Mayo Clinic interpreter.Patient's primary language: must have at least 0 and no more than 256 characters.The value of the Patient's primary language: field is not valid.

Interpreter needed:

Yes

Interpreter language:

Interpreter language: must have at least 0 and no more than 256 characters.The value of the Interpreter language: field is not valid.

Diagnosis/symptoms:

(please be specific)Diagnosis/symptoms: must have at least 0 and no more than 512 characters.The value of the Diagnosis/symptoms: field is not valid.

Appointment date requested first choice:

Appointment date requested second choice:

Appointment site requested:

Jacksonville

Rochester

Arizona

(required)

Appointment type requested:

General Medical Examination

Department/Specialty

Specify Department/Specialty:

Specify Department/Specialty: must have at least 0 and no more than 256 characters.The value of the Specify Department/Specialty: field is not valid.

Referring Person Information (if applicable)

Referring person's name:

Referring person's name: must have at least 0 and no more than 256 characters.The value of the Referring person's name: field is not valid.

Relationship to patient:

Relationship to patient: must have at least 0 and no more than 256 characters.The value of the Relationship to patient: field is not valid.

Address:

Address: must have at least 0 and no more than 256 characters.The value of the Address: field is not valid.

City:

City: must have at least 0 and no more than 256 characters.The value of the City: field is not valid.

Province/Dept:

Province/Dept: must have at least 0 and no more than 256 characters.The value of the Province/Dept: field is not valid.

Postal code:

Postal code: must have at least 0 and no more than 256 characters.The value of the Postal code: field is not valid.

Country:

Country: must have at least 0 and no more than 256 characters.The value of the Country: field is not valid.

Phone:

Phone: must have at least 0 and no more than 256 characters.The value of the Phone: field is not valid.

Mobile phone:

Mobile phone: must have at least 0 and no more than 256 characters.The value of the Mobile phone: field is not valid.

Fax:

Fax: must have at least 0 and no more than 256 characters.The value of the Fax: field is not valid.

E-mail:

Enter a valid email address.

Survey Questions

Is your decision to come to Mayo Clinic mostly your own or did another person significantly influence you?

Mostly myself

Another person

Your doctor at home

None

Some

A lot

A relative or friend

None

Some

A lot

A Mayo Clinic employee

None

Some

A lot

A Mayo Clinic representative in your country

None

Some

A lot

Your employer

None

Some

A lot

Someone else (please specify)

None

Some

A lot

Specify someone else come to mayo

Specify someone else come to mayo must have at least 0 and no more than 256 characters.The value of the Specify someone else come to mayo field is not valid.

None

Some

A lot

Radio

None

Some

A lot

Internet: Mayo web site

None

Some

A lot

Internet: Other web site

None

Some

A lot

Mayo Clinic newsletter

None

Some

A lot

Mayo advertisement in newspaper or magazine

None

Some

A lot

Mayo Clinic event in your country

None

Some

A lot

Newsletter

None

Some

A lot

Newspaper article

None

Some

A lot

Magazine article

None

Some

A lot

Medical Journal

None

Some

A lot

Mayo Clinic's general reputation

None

Some

A lot

Information provided to you by your insurance company

None

Some

A lot

Something else (please specify):

None

Some

A lot

Specify someone else sources of information

Specify someone else sources of information must have at least 0 and no more than 256 characters.The value of the Specify someone else sources of information field is not valid.

Important: After submission, please do not leave this form until you see the confirmation message.

Mayo Clinic Number

Your Mayo Clinic number is a 7, 8 or 9-digit number we assign to you as a new patient prior to your first visit. You can find it near the top of a range of documents, including pre-visit questionnaires, clinical notes, care summaries, and correspondence.

If you do have Mayo paperwork handy, it's often quickest simply to look for it there. Scroll down to see some examples of how the number shows up: