Preamble :
⚠️ - This form is intended to help the ELSAN team clearly understand your medical needs in order to determine whether an ELSAN solution can be provided.
Before proceeding, please ensure that the following points are met. Kindly note that if you are unable to provide the requested documents, our team will not be able to process your request
I am in possession of a comprehensive medical file, which includes a letter from my primary care physician and/or a specialist outlining the medical history, current symptoms, relevant medical background, treatments previously administered, clinical findings, medical recommendations, and test results...
My medical documents are recent (less than 3 months old) and of high quality. They clearly state the patient's full name, date of birth, and the date of issue. (Accurate identification on medical records is essential to avoid medical errors).
I understand that medical care is the patient’s financial responsibility and will be subject to advance payment based on a financial estimate.
In the case of a VISA request, administrative documents (such as an invitation letter and proof of payment) will be issued only after full receipt of the required funds.
I am filling out this application for myself
What is the reason of your request ?
- Select a reason I would like to apply for medical care A second medical opinion (with no specific intention of traveling to France) Business approach (BtoB) Other
Personal information
Patient nationality:
- Select Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua & Barbuda Argentina Armenia Aruba Ascension Island Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia & Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Canary Islands Cape Verde Caribbean Netherlands Cayman Islands Central African Republic Ceuta & Melilla Chad Chile China Christmas Island Clipperton Island Cocos (Keeling) Islands Colombia Comoros Congo - Brazzaville Congo - Kinshasa Cook Islands Costa Rica Croatia Cuba Curaçao Cyprus Czechia Côte d’Ivoire Denmark Diego Garcia Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Eswatini Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard & McDonald Islands Honduras Hong Kong SAR China Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao SAR China Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Northern Mariana Islands North Korea North Macedonia Norway Oman Outlying Oceania Pakistan Palau Palestinian Territories Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Romania Russia Rwanda Réunion Samoa San Marino Sark Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia & South Sandwich Islands South Korea South Sudan Spain Sri Lanka St. Barthélemy St. Helena St. Kitts & Nevis St. Lucia St. Martin St. Pierre & Miquelon St. Vincent & Grenadines Sudan Suriname Svalbard & Jan Mayen Sweden Switzerland Syria São Tomé & Príncipe Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad & Tobago Tristan da Cunha Tunisia Turkmenistan Turks & Caicos Islands Tuvalu Türkiye U.S. Outlying Islands U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis & Futuna Western Sahara Yemen Zambia Zimbabwe Åland Islands
Are you covered by the French social security system ?
Do you have private insurance ?
Are you already in France ?
- Select YES , the patient is already in FranceNO , the patient is not in France but possesses a valid VISA NO, the patient is not in France and will need to apply for a VISA NO , the patient is not in France but does not require a VISA
Does the patient have a geographical preference for their medical care in France? Please specify a city so that we may contact the nearest ELSAN healthcare facility to your preferred location.
Medical information :
Nature of pathology :
- Select a pathology Vascular surgery Orthopedic surgery Cardiac and thoracic surgery Cosmetic and reconstructive surgery Urological surgery Ophthalmologic surgery Visceral and digestive surgery Proctologic surgery ENT surgery (Ear, Nose, and Throat) Gynecological surgery Health check-ups Dialysis Bariatric surgery Neurosurgery (spine, cervical) Medical rehabilitation care Other
Please specify your request (needs, medical history, requirements…):
How did you hear about the Elsan International Office?
- Select Internet search Social media Recommendation by an Elsan doctor Recommendation by a friend or family member Recommendation by your insurance company Trade fairs / exhibitions Advertising / press Other
We recommend that users do not submit sensitive data that is not relevant to the purpose of this form.
By submitting this form, I agree that the data entered will be processed by the ELSAN’s International Patient Office in order to be contacted, so that a proposal for treatment in one of the Group's facilities and an associated estimate can be sent to me.
By submitting this form, I agree that the information entered in it will be used to allow a personalized study to be carried out and to ensure the proper processing of my requests.
Les informations recueillies via ce formulaire sont enregistrées dans un fichier informatisé par ELSAN afin de réaliser une étude personnalisée et de fournir un devis adapté à chaque patient international. Conformément à l’article 6.1 f) du Règlement européen sur la protection des données, ces informations sont donc traitées sur la base légale de l’intérêt légitime du Groupe ELSAN à savoir la réalisation de devis de patients internationaux.
Conformément à l'article 9 h) du RGPD, le traitement des données sensibles est autorisé lorsqu’il est nécessaire à des fins de prise en charge sanitaire. Cette exception permet à ELSAN de traiter des données relatives à la santé, ce qui justifie le traitement de données sensibles, en principe interdit.
Les données collectées seront communiquées aux seuls destinataires suivants : les praticiens du Groupe ELSAN et le Bureau des patients internationaux du Groupe ELSAN pour être recontacté(e), afin qu’une proposition de prise en charge dans un Etablissement de santé du Groupe ainsi qu’un devis associé puissent être établis.
Les données personnelles du patient sont conservées durant la durée strictement nécessaire au traitement de la demande.
Vous pouvez accéder aux données vous concernant, les rectifier, demander leur effacement, exercer votre droit à la limitation ou s’opposer au traitement de vos données.
Pour exercer vos droits Informatiques et Libertés, vous pouvez contacter notre délégué à la protection des données en écrivant à l’adresse dpo@elsan.care ou à l’adresse postale suivante : ELSAN 58 bis Rue de la Boétie 75008 Paris
Si vous estimez, après nous avoir contactés, que vos droits Informatiques et Libertés ne sont pas respectés, vous pouvez adresser une réclamation en ligne à la CNIL (cnil.fr/plaintes) ou par courrier postal.
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