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.

Contact Details
Last Name
First Name
Father's Name
Country of birth
Birth Date
/ /
Valid Passport


Marital Status


Number of children
City
Country
Home phone number
Mobile
Fax number
Your email address (Required)
Former Education
Occupation
Other relevant personal remarks
 
Telephone +972-8-6755010 Email contact@anrclinic.info

Please call us

Dr Waismann will be pleased to answer any questions you might have on dependency to painkillers, or any other opiate based medication, such as OxyContin®, Suboxone, Methadone, Codeine, Darvocet, Percocet®, Dilaudid®, Heroin, Hydrocodone, LAAM, Lorcet®, Lortab®, MS Contin®, Norco®, Percodan®, Stadol®, Tramadol, Vicodin®, and Zydone®.

Your Wellbeing Is Our Only Concern

If you are considering an alternative rapid detox or Opiate addiction treatment, please ask the following questions:

  • Who will carry out the procedure?
    If it is not qualified anaesthetists and ICU staff, alarm bells should start to ring!
  • How long will I have to take Naltrexone after the procedure?
    This can only be determined during the actual treatment. Each patient's needs differ.
  • What dosage of Naltrexone will I need to take?
    Again, this can only be determined during the actual treatment and a predetermined dosage can lead to severe side effects.