Medical Form

Prefix

First Name *

Last Name *

Email Address *

Phone

Date of Birth *

Day

Month

Year

How would you like to be contacted?Please select an option from the dropdown menu

A bit about you

Weight

Unit of WeightPlease select an option from the dropdown menu

Height

Unit of HeightPlease select an option from the dropdown menu

GenderPlease select an option from the dropdown menu

Street Address

Apartment, suite, etc

City

Country

Purpose of your visit

Check all you need

Medical AppointmentSurgicalWellnessSecond Opinion

Description of your health/medical needs

Past Medical History

Are you currently pregnant?Please select an option from the dropdown menu

Past Surgical History

Did you had any Surgery?YesNo

If YEs

Any complications from Surgery or Anesthesia?YesNo

Any Allergy to?:

Select all that apply

NoneDrugFoodSeasonal

Smoking/Alcohol/Drugs?:

Select all that apply

Smoking HabitAlcohol ConsumptionRecreational Drug use

Checklist of previous illness

If you feel there are any further details which may help us in providing you with their appropriate treatment/surgery information, please specify below

GDPR *Yes, I agree with the privacy policy and terms and conditions.

Disclaimer

MedicaBooking.com does not provide advice on medical treatments nor make claims or guarantee on the outcome of any medical treatments or surgery.

Before making any related decision you must thoroughly discuss and seek advice from one of our qualified medical professional

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