Book a Home Visit

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BOOKING ID

Some fields are mandatory so as to assist you and invoice the service we will provide (*)

I have already received confirmation of service cover and fees at my address by Medelit's Operations Team, and now want to proceed with a BOOKING.*

Yes

No

PLEASE TAKE NOTICE - This is not an enquiry form. Please do NOT use this form prior to contacting us for confirmation of cover and fees at your address. WE only provide home healthcare services in ITALY.

This is a booking form. Please contact us by chat, phone or through our info request form to receive information regarding cover of service and fees for your area

I am*

A New patient

A returning patient

I AM BOOKING:*

HOME VISIT

ONLINE SERVICE

PATIENT Name and Surname*

First Middle Last

Email*

Enter Email Confirm Email

Date of Birth*

Do You have an italian CODICE FISCALE?*

CODICE FISCALE*

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RETURNING PT ID

PT ID

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New/returning PT

Country of Birth*

Telephone for Contact*

Provide a MOBILE number

Telephone 2

Please leave us 2 phone numbers if possible

Home visit information

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Visit Address on System

Street Address City County / State / Region ZIP / Postal Code Country

Is the visit always at the same Address?*

Is the Invoicing Address always the same?*

Updated Invoicing Address*

Street Address City County / State / Region ZIP / Postal Code Country

Visit Address*

Street Address City County / State / Region ZIP / Postal Code Italy

Updated Visit Address*

Street Address City County / State / Region ZIP / Postal Code Country

Street Level Intercom*

Updated Street Level Intercom*

Floor*

Updated Floor*

Apt/Staircase*

Updated Apt/Staircase*

Invoice Information

Is your invoicing Address the same as your visit Address?*

Yes

No

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System Invoicing Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Invoicing Address*

Street Address City County / State / Region ZIP / Postal Code Country

How do You Prefer to Pay for the visit?*

Voucher Number*

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VOUCHER FOUND

Invalid Voucher

Sorry, this voucher number is not valid.

How did you find us ?*

GP/Other Doctor

Word of mouth

Family/Friends

Hospital/Clinic

Insurance

Search Engine

Leaflet

Book A Home Visit

Some fields are mandatory so as to assist you and invoice the service we will provide (*)

This is a booking form. Please contact us by chat, phone or through our info request form to receive information regarding cover of service and fees for your area

Home visit information

Invoice Information

BOOKING INFORMATION