Glory Assistance

Evaluation Getting started

Glory Assistance Evaluation

Let’s understand your situation

Answer a few questions about your medical treatment needs and travel plans. Your answers will help Glory Assistance understand your situation and determine how we may assist you.

Takes only a few minutes

Step 1

What type of assistance are you looking for?

Choose the option that best describes what you need from Glory Assistance.

* Required

Medical treatment abroad

Medical treatment + visa assistance

I’m not sure yet

Please select one option to continue.

Step 2

Who needs medical assistance?

Tell us who the treatment is for.

* Required

Myself

My child

My spouse

Another family member

Someone else

Patient’s age *

Please select the patient’s age range.

Step 3

Tell us about the medical situation

We only ask for information that helps us understand the type of medical assistance being requested.

* Required · Fields marked Optional do not need to be completed.

What type of medical assistance are you seeking? *

Please select the type of medical assistance.

Please specify *

Please specify the type of medical assistance.

Have you already received a medical diagnosis? *

Yes

I’m not sure

What is the diagnosis? *

Please briefly describe the diagnosis.

Briefly describe the medical problem *

Please briefly describe the medical problem.

Tell us briefly what you know *

Please provide a brief description.

Step 4

Has the patient already received treatment?

This helps us understand whether the request concerns new treatment, continuation of care or another opinion.

* Required

Yes

Currently receiving treatment

Where was the treatment received? *

Please enter where the treatment was received.

What treatment was provided? *

Please select the treatment provided.

Please specify the treatment *

Please specify the treatment.

Step 5

Do you have medical documents?

Medical reports can help us understand the case. You can continue even if you do not have documents.

* Required

Yes, I have medical documents

I have some documents

No documents available

You can send your medical documents after submitting this evaluation.
Please email your medical reports, test results, scans, prescriptions, or other relevant documents to contact@gloryassistance.com.

After you submit the evaluation, you will receive an Evaluation Reference Number (for example, GA-2026-0006). Please include that reference number in your email so we can match your documents to your evaluation.

You can continue without documents.

Step 6

Where would you like to receive treatment?

Tell us your preferred treatment destination. If you are considering another country, choose it from the list.

* Required

Hospital Country *

Please select a treatment destination.

Please select the country *

Please select the country.

Please specify *

Please specify the country.

Do you already have a hospital or doctor in mind? Optional

Yes

No, I need assistance

Hospital or doctor name Optional

Step 7

How soon do you need assistance?

This helps our team understand the timing of your treatment project.

* Required

As soon as possible

Within the next few weeks

Within 1–3 months

I’m only planning for now

Visa Assistance

Let’s understand your travel and visa needs

Because you selected medical treatment together with visa assistance, we need a few additional details about your international travel history and visa situation.

These questions are only shown because you requested medical treatment + visa assistance.

Visa — Step 1

Have you travelled internationally before?

This helps us understand your previous international travel experience.

* Required

Yes

Which countries have you travelled to? *

You can select more than one country.

Please select at least one country.

Visa — Step 2

Have you previously had a visa refused or rejected?

Please answer honestly. This information helps us understand your previous visa history and provide more appropriate guidance.

* Required

Yes

Which country refused your visa? *

Please select the country.

Please specify *

Please specify the country.

When was the refusal? Optional

Do you know the reason for the refusal? Optional

Visa — Step 3

Which country do you intend to travel to?

Tell us the country where the medical treatment will take place.

* Required

Intended destination *

Please select your intended destination.

Please specify *

Please specify the country.

What type of visa assistance do you need? *

Medical visa

I’m not sure

Visa — Step 4

Do you currently have a valid passport?

A valid passport is generally required for international travel and visa processing.

* Required

Yes

Yes, but it is expired

No, I don’t have one

Visa — Step 5

When would you like to travel?

This helps us understand the timing of your medical treatment and visa process.

* Required

As soon as possible

Within the next few weeks

Within 1–3 months

Planning for later

Final Information

Tell us how we can contact you

We need a few details so our team can follow up regarding your request.

* Required · Optional fields are clearly marked.

Full name *

Please enter your full name.

Country of residence *

Please enter your country of residence.

City Optional

Phone / WhatsApp *

Please enter your phone or WhatsApp number.

Email address *

Please enter a valid email address.

Who should we contact about this request? *

The patient

A family member

Another representative

Additional Information

Is there anything else we should know?

This is optional. You can provide any additional information that may help us understand your request.

Additional information Optional

Before Submission

Please confirm your information

Before reviewing your request, please confirm the following.

* Both confirmations are required

I confirm that the information I have provided is accurate to the best of my knowledge. *

I consent to Glory Assistance processing the information I have provided for the purpose of evaluating and responding to my request. *

Please confirm both statements before continuing.

Your information will be used to evaluate your request and allow Glory Assistance to respond to you.

Final Review

Review your request

Please check the information below before submitting your evaluation request.

You can go back and make changes before submitting.

✓

Request Received

Thank you for contacting Glory Assistance

Your evaluation request has been received successfully. An expert will review the information you provided and contact you within 48 hours.

If you do not receive a reply within 48 hours, kindly contact us using the email below:
contact@gloryassistance.com

Reference: GA-2026-0000