Dr Waismann Clinic - Opiate dependency treatment center for rapid detox using the ANR Method

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Medical Form

Please provide us with your personal information. This will be treated with total confidentiality.

In order to undergo our treatment, we first ask you to complete our the medical form below. This will be reviewed by Dr. Waismann before we contact you to arrange your travel and accomodation.

Your stay will be one week. When you land, you will be picked up at the airport by our staff and transported to the Dr.Waismann Clinic for a first consultation, evaluation and medication that will allow you a comfortable pre-hospitalisation stage.

After the hospitalisation period, you will stay in a modern, first-class hotel which offers all the facilities you need to recover in the best conditions. Dr.Waismann will visit the patient during this recuperation phase.

After your week is over, you will be transferred to the airport to fly home and start afresh.

Personal details
Please enter your surname
Please enter your first name
Please provide your Father's fullname
Please enter the country in which you were born
Please enter your date of birth
/ /
Have you a valid Passport?


Please select your marital status


How many children or dependants do you have?
Please enter the city of your address
Please enter the country where you live
Please provide your home phone number plus international code
Please enter your mobile phone number
Please provide your Fax number
(Required)
Please provide details of your education
Please inform us of your present occupation