Omnity “My Wish” Initiative

Note

A wish is granted no sooner than two weeks from the date of the request, once it has been approved.

Wish Request Form

Contact details

Branch: *
Specialist's name: *
Email address: *
Extension number: *

Patient details

MCD: *
File number: *
Patient's name: *
Place of residence: *
Nationality: *
Age: *
Sex: *
Is the patient registered with social security? *
Financial circumstances: *
Expected length of stay: *
Medical condition: *

Wish details

I would like to have: *
I would like to be: *
I would like to be at: *
I would like to meet: *