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Patient Admission Form

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Dear Patient,

Welcome to our clinic! Your health is our priority and that is why we are here to welcome you in the best way possible. Please help us by filling out the patient intake form below. Your information is very important for us to provide you with the most appropriate service. If you have any questions or need assistance, please do not hesitate to contact our team members. We are happy to support you on your path to regaining your health.

We wish you healthy days!

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1. Are you currently receiving medical treatment from a doctor, hospital or clinic?
2. Do you use a prescription drug
3. Do you carry a medical alert card?
4. Are you allergic to any food, drug or substance? E.g; Latex, Penicillin
5. Do you have hay fever?
6. Do you have hay fever or eczema?
7. Do you have bronchitis, asthma or any other chest condition?
8. Do you suffer from fainting, dizziness, blackouts or epilepsy?
9. Do you have heart problems?
10. Do you have any angiography problems?
11. Do you suffer from heart, angina, blood pressure problems or stroke?
12. Do you have diabetes?
13. Do you have any contagious disease?
14. Have you tested positive for any disease such as HBsAG, HCV, HIV?
15. Do you have liver or kidney disease?
16. Do you have any other serious illness?
17. Has your blood been rejected by blood collection facilities?
18. Have you ever had a bad reaction to local or general anesthesia?
19. Do you have prostheses or implants in your body?
20. Have you had an operation related to the heart?
21. Do you smoke?
22. Do you drink alcohol?
23. Are you pregnant?
24. Have you had Covid-19 or have you had a test?
Require Your Accept
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Would you like an appointment or more information? +90 533 788 37 83​ You can get in touch by calling this number.

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