Search Here:
Refer a Friend
Request for Information  
  Request Info Regarding :

Let us help you find healthcare providers specific to your treatment needs and choice of destination(s).

Our “Request for Information” service, enables you to achieve this quickly and efficiently. Complete the Request for Information form below for the kind of treatment that you are seeking, select the countries that you are interested in and you will get a response from healthcare providers matching your specific needs.

Your request will be forwarded to various PlacidWay partner providers matching your specific treatment and country criteria.

Free Service • No Obligation • Quick & Easy
How would you like to be reached ?
Your Name *
Your Email *
Phone Number *
Mailing Address
Address 2
City *
Country *
Zip / Postal Code
Tell us about yourself...
Age Range
Male Female
Preferred Language
  Newsletter Subscription
What treatment and countries would you like information?
Treatment *
Country 1 *
Country 2
Country 3
Treatment Description
When you would like to be treated?
Questions / Additional Information
Check to Accept Terms & Conditions
Enter the above security code: *
     * Indicates Required Information respects your privacy. This form sends an email to the facility or provider that matches your profile or the information you have provided to us. Please note the United States mandated Health Care Portability and Accountability Act does not apply to those health care providers outside of the United States. Do not send sensitive or personally identifiable information via email, as email does not provide a secure means of transmitting information. Do not disclose anything via email that you would normally not wish to send via email, such as credit card information. The health care provider who receives your communication will make every effort to communicate with you.
© PlacidWay, LLC 2007 - 2014. All Rights Reserved