Funding For Treatment In The European Economic Area (Eea) Application Form Page 5

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d)
What are / were the specific DATE(S) for the treatment(s) abroad?
(complete where applicable)?
In-patient stays
(i.e. overnight stays
in hospital)
Day case
appointments (e.g.
day case surgery)
Out-patient
appointments (e.g.
clinics / check-ups /
consultations)
Other
appointments
(e.g. physiotherapy)
Diagnostics tests
(e.g. Blood tests /
scans)
Equipment /
Appliances issued
(e.g. walking aids,
hearing aids)
Medication Name
Type (e.g.
Strength
Quantity (e.g.
tablets, gel,
(e.g. 50mg)
1 x box 50
cream, liquid)
tablets, 1 x
100ml bottle)
Drugs / Medication
paid for
Other, please
specify
e)
Are you applying before treatment?
Yes
No
If Yes go to (f), below, if No go to (g)
f)
What are the estimated costs of the treatment?
9a. EEA application form (10 /14)
Page 5 of 10

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