Medical Treatment Visa Application Form
Personal Details
Full Name
Date of Birth
Gender
Male
Female
Other
Nationality
Passport Number
Passport Expiry Date
Email Address
Contact Number
Medical Details
Description of Medical Condition
Name of Hospital in Destination Country
Hospital Address
Treating Doctor’s Name
Expected Duration of Treatment
Proposed Treatment Start Date
Proposed Treatment End Date
Accompanying Person (if any)
Full Name
Relationship
Passport Number
Declaration
I declare that the information provided is true and correct.
Signature
Date