CubaHeal

PATIENT MEDICAL PROFILE

Required to prepare your official dossier for submission to the Cuban Medical Authorities

The Cuban Medical Authorities can only study your case and decide on a suitable program after receiving a complete and detailed medical profile.

The more accurate and complete your answers, the better the specialists can evaluate your situation.

Average time to complete this form is approximately 5 to 10 minutes.

If you would like support while completing this form, you may request a short Zoom session with our team. Details are provided in the email you received.

CA1 Patient Medical Profile (Stripe)

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This information identifies you in the Cuban Medical Authorities records and ensures that all documents are correctly linked to your case.

Full Name

First Name

Last Name

Date of Birth

Citizenship

Country of Residence

Email Address

Phone Number

Emergency Contact Name

First Name

Last Name

Emergency Contact Relationship

Email Contact Email Address

Emergency Contact Phone Number

Telephone Number of Unattended Decision Maker

If you are human, leave this field blank.

Treatment Programs