ANAMNESIS FORM

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ANAMNESIS FORM

Please fill in the required information below

Name *

First

Last

Passport Number *

Email Address *

Email

Confirm Email

Mobile Phone *

Please enter a valid phone number including Country code

Discount Code

Do you have any heart disease? *

Yes
No

What type of treatment? *

Rhinoplasty
Dental
Hair Transplant
Obesity Surgery
Ophthalmology
Orthopedics

Do you have a complaint about blood pressure? *

Yes
No

Do you have diabetes? *

Yes
No

Have you ever had a rheumatic disease? *

Yes
No

Do you have any blood disease? *

Yes
No

Do you have a pregnancy status? *

Yes
No

Are you under the control of a doctor due to any illness? *

Yes
No

Are there any medications or drugs that you use regularly? *

Yes
No

Have you ever had jaundice? If so, what type is it? A B C *

A
B
C

Are you allergic? Are you allergic to a drug? *

Yes
No

Do you have kidney, liver or any other organ disease? *

Yes
No

Do you receive chemotherapy or radiotherapy? *

Yes
No

Have you recently returned from abroad? *

Yes
No

Have you had a flu infection recently? *

Yes
No

Do you have any other diseases that we should know about? *

Yes
No

I accept that the above information is correct and that the necessary treatments are done. Within the scope of the Personal Data Protection Law, I consent to the processing and storage of the data in this form in accordance with the purpose within your center for the establishment of my patient record, financial transactions and realization of my treatment with my own consent. *