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Asian Hospital and Medical Center is happy to provide the estimated cost of care for consultations, testing, procedures or surgeries. In order to make the best possible estimate, please complete the form below and submit. We try to respond within 3 working days.
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Patient's
Name (if different than your own) |
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Patient's First Name: |
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Patient's
Middle Name(s): |
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Patient's
Last Name: |
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ABOUT
YOUR MEDICAL CONDITION
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Your
Diagnosis or Condition?* |
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Do
you have results from tests or investigations at other hospitals
that you can share with us? |
Yes
No
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Do you have a personal physician that you would like us to communicate
with directly? |
Yes
No |
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If
yes: |
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First
Name: |
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Last
Name: |
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E-mail:
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Have
you selected an AHMC Physician? |
Yes
No |
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If
yes: |
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First
Name: |
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Last
Name: |
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Specialty:
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FOR
WHAT SERVICES DO YOU WANT AN ESTIMATE? |
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Testing
(Lab, X-rays, etc) |
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Physician
Consultation |
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Surgery
(specify type if known) |
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Other
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| DISCLAIMER
NOTICE |
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Prices
will be for rough planning purposes only to assist the patient
in understanding the possible range of costs. Actual estimates
for care cannot be accurately provided until the patient has
been thoroughly examined by the AHMC physician. The cost ranges
provided are based upon our best understanding of the patient's
condition at the time of contact and do not represent a minimum
or maximum potential cost.
Thank you for your trust in Asian Hospital and Medical Center.
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