E-Consultation

Your full name *

Date of birth *

Height *

Weight *

Age *

Country *

City *

Your e-mail address *

Country code *

Your phone number *

How did you reach us? *

Medical Information

Do you have heart disease? *

Do you have any respiratory problems? *

Do you have any blood related disease? *

Do you have a chronic illness? *

Do you have any allergies? *

Do you have a mental illness? *

Do you take medication? *

If you are taking medication;

What do you take medicine for?

What is your medicine dose?

How long have you been on medication?

Have you had surgery before?

Did you have any problems during anesthesia?

Is there anything else you want to inform us about?

Do you smoke, drink alcohol or use drugs? *

Operation

Which operation are you interested in? *

What is your expectation?

What are your complaints?

File Attachments

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