Request an Appointment

Please complete the simple form below, including as many details as possible, in order to help us identify a specialized physician to meet your specific needs.

Who is this appointment request for?

Myself

Someone else

Is this the first time visiting?

Yes

What's your relationship to the patient?

Your Contact Information

Your First Name

Family/Last Name

Phone Number

Email Address

Patient Information Your Information

Please ensure that the following information is provided exactly as it appears on the patient's Emirates ID or passport.

Patient First Name

Patient Family/Last Name

Date of Birth

Date

Month

Year

Please note, we are unable to accept patients under the age of 14, with the exception of our Eye Institute and Emergency Medicine Institute.

COUNTRY OF RESIDENCE

Patient Phone Number

Patient Email Address

Preferred callback time

Reason for Visit

Please Type Other Source

New patients to Cleveland Clinic Abu Dhabi may provide additional details below to expedite registration.

Additional Patient Information

Gender

Male

Female

Patient Nationality

Patient Emirates ID #

The patient does not have an Emirates ID #

Patient Address

COUNTRY OF RESIDENCE

Apartment or Villa or Building Name/Number

Address line 1

Address line 2

City

PO Box

Patient Health Insurance

By providing patient health insurance details, we will verify your policy coverage and discuss with you if and how it applies at Cleveland Clinic Abu Dhabi.

How would you like to pay for treatment at Cleveland Clinic Abu Dhabi?

Health insurance

Self payment

Please complete the fields below and click here to upload your insurance documents.

Health Insurance Payer

Group/Policy Information