International Health Services - Booking and Referral portal

Please fill the form the online booking/ referral form below and we will get back to you by 10am CET the next working day

I am ….
I am requesting ….
Diagnosis/Suspected condition
Service/Specialty requested
Patient's details
Family Name (as appears on passport)  *
Given Name (as appears on passport)  *
Birth date day  month  year 
I am a citizen of the following Nation
Phone number on which you can be contacted  *
Secondary telephone number (optional)
Email address  *
You prefer to be contacted primarily by
Please add any information regarding patient/history, reason for referral you think we should know before we reach out to you, in order to best deal with your request
Medical Information
Click here if you would like our Medical Liaison Officer to get in touch with you to discuss your admission
Click here Click here if you would like our Medical Liaison Officer to reach out to your treating doctor beforehand for additional information
Administrative and Billing
Click here if you wish to be contacted beforehand by our admin department regarding admin/payment/billing information.
Cultural mediator
Click here if you wish to be assisted by a cultural mediator/translator in a language other than English
My language is
Personal data treatment consent
With reference to Legislative Decree n. 196/03, art. 13 (Law about personal data protection), we hereby inform you that your consent to the treatment of your personal data is required to allow you sending the filled referral form. Your personal data will be filed in our archives and processed both by paper and electronic format, in compliance with all the security and confidentially measures fixed by Law, Exhibit B. Your personal data may be transmitted to third party that should carry on all the necessary activities to manage your request. We inform you that the Data Controller is “Ospedale San Raffaele s.r.l.”, with legal office in Milan, Via Olgettina n. 60 . We also specify that art. 7 of the Law attributes specific rights to citizens. In particular, you may obtain the access to your data or obtain their updating, correction , integration, deletion, the turning in anonymous form (if it is possible) or the blocking of any data treated in breach of the law. We should inform you that your refusal to authorize the use of your personal data will not allow us to carry out the requested services.