Online Consultations

Name of patient *

First Name

Last Name

Phone *

Country

(###)

###

####

Date of Birth *

MM

DD

YYYY

Which consultation are you requesting? *

Initial Consultation

Follow-up Consultation

Second Opinion

Urgent Consultation

Data Consent *

By submitting this form, I acknowledge that I am providing personal and medical information to EVA Clinic for the purpose of reviewing my case and arranging an online medical consultation. I understand that: My data will be stored securely and accessed only by authorized EVA Clinic staff. EVA Clinic complies with the General Data Protection Regulation (GDPR) and treats all data confidentially. I have the right to access, correct, or delete my data at any time by contacting EVA International / EVA Clinic.

I give my explicit consent to EVA International / EVA Clinic to process my personal and medical data for the purpose of reviewing my case and arranging a consultation, in accordance with the data consent form.