Patient Information & Care Request

This secure form helps us understand your needs and prepare a personalized medical plan and transparent quote.

Returning patient? Sign in to continue your previous request or access your medical records.

Step 1 of 5: Personal Info

Personal Info

Medical Info

Documents

Travel Plans

Review & Submit

Tell Us About Yourself

We need this information to coordinate your care and travel

First Name *

Last Name *

Email Address *

We will send your personalized quote here

Phone Number *

Include country code (e.g., +250 for RDA)

Date of Birth *

Gender *

Nationality *

Current Country *

Preferred Language

Your information is protected with enterprise-grade security and HIPAA compliance

Kigali/Rwanda

Monday - Friday 8:30 AM - 6:00 PM

Saturday 9:00 AM - 1:00 PM

Sunday Closed

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+250 798205731

support@medgate.rw

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