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Information Request

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If you have a medical question for our Clinic, feel free to fill out and submit the form below. This service is offered to you free-of-charge. You will receive an answer by email, so make sure you've entered a valid email address.

Your Request
Subject*:
Message type:
Please reply     For your information
 
Priority:
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For Urgent matters, please call !
Imaging / X-rays uploads, only format JPG, TIF, or PNG!! Size 20 kB to 6 MB.
Image 1:
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Image 2:
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Image 4:
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Your Request*:
Patient Data
Gender*:
Male   Female
Firstname*:
Family name*:
Birth date*:
format: DD/MM/YYYY
Street:
House number:
ZIP Code:
City:
State:
Country*:
Telephone*:
Email*:
Email again*:
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Verification code*:
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If you have problems using this form, or didn't receive an answer within 5 days, please contact the This e-mail address is being protected from spambots. You need JavaScript enabled to view it .
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The information given on the ANCA-Clinic website is regulary reviewed by the Health on the Net Foundations for compliance to the HONcode principals.

We subscribe to the HON-code principles. Verify here.

Contact Belgian Clinic

helpdeskFor international contact with our main office in Belgium, please use the information given below:

Contact Italian Clinic

For a direct contact with our Itailian Clinic at Rome, use the information given below: