Ask our international team about your medical case You must have JavaScript enabled to use this form. Toute demande d'analyse de dossier pour les patients internationaux est soumise à un règlement de frais de gestion de 150€. Ce règlement vous sera demandé après avoir rempli le formulaire. ATTENTION, si vous ne vous acquittez pas de ces frais, votre dossier ne pourra être étudié par nos équipes. You are - Select -An international patient with no French social security numberUn patient européen possédant une carte européenne de santéAn international doctor asking for a second opinion for my patientA relative or friend of an international patientAutre Patient’s information Surname First name Date of birth Gender Male Female Phone number Email address Mailing address Adress City/Town Code Postal Pays Country - None -AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua & BarbudaArgentinaArmeniaArubaAscension IslandAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia & HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCanary IslandsCape VerdeCaribbean NetherlandsCayman IslandsCentral African RepublicCeuta & MelillaChadChileChinaChristmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo - BrazzavilleCongo - KinshasaCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d’IvoireDenmarkDiego GarciaDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard & McDonald IslandsHondurasHong Kong SAR ChinaHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacao SAR ChinaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)NamibiaNauruNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern Mariana IslandsNorth KoreaNorth MacedoniaNorwayOmanOutlying OceaniaPakistanPalauPalestinian TerritoriesPanamaPapua New GuineaParaguayPeruPhilippinesPitcairn IslandsPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSamoaSan MarinoSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia & South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSt. BarthélemySt. HelenaSt. Kitts & NevisSt. LuciaSt. MartinSt. Pierre & MiquelonSt. Vincent & GrenadinesSudanSurinameSvalbard & Jan MayenSwedenSwitzerlandSyriaSão Tomé & PríncipeTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad & TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks & Caicos IslandsTuvaluU.S. Outlying IslandsU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamWallis & FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Passport Please attach now a copy of your passport in international lettersOne file only.6 MB limit.Allowed types: pdf, jpg, jpeg, png. Carte européenne de santé Une copie de votre carte européenne de santéOne file only.3 MB limit.Allowed types: pdf, jpg, jpeg, png. Contact information Since you are contacting us on behalf of another person, we also want to have your contact details. Surname First name Phone number Email I wish to I wish to - Select -Refine my Diagnosis Discuss treatment options and / or get a second opinionGet medical care at the Léon Bérard centerGet a medical opinion for pediatric hematologic cancer For pediatric hematological cancer, you must contact IHOPE directly on +33 (0)4 69 16 65 50 or +33 (0)4 69 16 75 50. Documents to attach to your request Please find below the list of documents which must then be sent to our service. These documents must be in .pdf format and we invite you to prepare them Medical imaging at least the pre and post operative imaging of each intervention and recent good quality imaging with the name of the patient and the legible examination date (Link to upload your images in DICOM format : https://webupload.acetiam.eu/upload/CLB/ ) Medical letter Recent medical letter from a referring oncologist including a complete and chronological summary of the diseaseOne file only.3 MB limit.Allowed types: pdf, jpg, jpeg, png. Treatments considered The treatments envisaged by the doctors in charge of the patientOne file only.3 MB limit.Allowed types: pdf, jpg, jpeg, png. Surgery reports Surgery reports with the patient name and the examination date legible on each pageOne file only.3 MB limit.Allowed types: pdf, jpg, jpeg, png. Histological reports Histological reports including immunohistochemistry with patient name and examination date legible on each pageOne file only.3 MB limit.Allowed types: pdf, jpg, jpeg, png. Chemotherapy reports The chemotherapy reports with the dates of the treatments, the name of the moleculesOne file only.3 MB limit.Allowed types: pdf, jpg, jpeg, png. Radiotherapy reports Radiotherapy reports with dates, doses received, volumesOne file only.3 MB limit.Allowed types: pdf, jpg, jpeg, png. Complementary information Complementary information Please write down any important information below that may help us respond to your request quickly. Applicant’s surname I certify making a request for a second opinion with the full information and agreement of the person concerned by the request By submitting this form, I accept that the information entered will be used to respond to my request. 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