International Patient Services Request Form

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If you require immediate assistance, call Baptist Health International 24 hours a day at 786-596-2373.

For general inquiries, fill out our contact form below. Please allow up to 48 hours for a response.

Please tell us about your request:

Diagnosis/Symptoms:

Medical Services Requested:

Preferred Start Date of Services:

Expected Services Complete Date:

How did you hear about Baptist Health South Florida?:

In-Country Manager/Representative: Please select if one of our In-Country Managers has assisted you

First Name*:

Middle Name/Initial:

Last Name*:

Date of Birth*:

Name of Parent/Guardian if patient is minor:

Parent/Guardian's DOB if patient is minor:

Home Phone (Please include country and city codes)*:

Other Phone:

Email Address:

Preferred Language:

Gender:

Race:

Religion:

Marital Status:

Diabetic:

Mailing Address Street:

Mailing Address Street 2:

Mailing Address City:

Mailing Address State:

Mailing Address Zip Code (or Postal Code):

Country:

Same as Mailing:

Billing Street:

Billing Street 2:

Billing City:

Billing State:

Billing Address Zip Code (or Postal Code):

Billing Country:

Hospitality Services: Click here for assistance with hotel reservations

Local Address:

Local Primary Phone:

Once the form has been completed, please click below to submit. Our team will contact you with instructions to send a copy of your photo identification, insurance card (front and back), medical records, and upload images.

I agree with the Terms for online assistance.*

International Patient Services Request Form

Contact Us

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