Title Dr Miss Mr Mrs Prof Rev First name (required) Last name (required)

Email (required) Phone Number (required)

Relationship to patient Husband Wife Spouse Child

Do you have permission to speak on behalf of the patient? Yes No

Title Dr Miss Mr Mrs Prof Rev First name (required) Last name (required)

Email (required) Phone Number (required)

Gender (required) Female Male Non-binary

Date of Birth (required) Is a diagnosis confirmed? Yes No

Patient script Attachments

Nationality Country of residence Algeria Angola Benin Botswana Burkina Faso Burundi Cabo Verde Cameroon Central African Republic Chad Comoros Congo Côte d'Ivoire Democratic Republic of the Congo Djibouti Egypt Equatorial Guinea Eritrea Eswatini Ethiopia European Union Gabon Gambia Ghana Guinea Guinea-Bissau Kenya Lesotho Liberia Libya Madagascar Malawi Mali Mauritania Mauritius Morocco Mozambique Namibia Niger Nigeria Rwanda Sao Tome & Principe Senegal Seychelles Sierra Leone Somalia South Africa South Sudan Sudan Tanzania Togo Tunisia Uganda United Kingdom Zambia Zimbabwe

Payer (required) Payment method (required)

person to be contacted Husband Wife Child Guardian Other

If you have selected 'other' please provide a contact email address and/or phone number

I confirm that I have provided all the information required to facilitate he processing of my inquiry. I hereby authorize ABX Health to contact me in relation to this request by way of email, phone, or any other communication channel deemed to be suited.