Application Form

Please fill out the form below to complete the order

Full Name in English

Full Name in Arabic

Date of Birth

Gender

Martial Status

Nationality

Phone Number

Address

Have you been treated before in Jordan?

Yes

Have you ever applied through Salamatk before?

Yes

Health status

Do you have medical insurance covered internationally?

Yes

Would you like to send your request to a hospital or to a doctor?

Hospital

Doctor

Hospital

Doctor