Patient information — Cuba Health Assist Application

Patient full name *

Patient gender *

MaleFemalePrefer not to say

Is the patient under 18? *

No, 18 or olderYes, under 18

For a patient under 18, the application is made by a parent or legal representative. You stay our contact person; we never ask for the patient’s own contact details.

Your relationship to the patient *

Our team may ask you for a document that shows this authority.

Nationality *

Patient country of residence *

Patient city *Select a city after choosing the country. Use Other if not listed.

Patient passport or ID image *

Upload passport or ID

PDF, JPG, JPEG or PNG file

A readable identity document is required. When editing an already saved patient step, the existing secure document remains attached unless you upload a replacement.