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Last name:
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Height (In Cms):
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Marital status :
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Single
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Do you smoke?:
Yes
No
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Do you drink alcohol?:
Yes
No
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Did you go through any operation before?:
Yes
No
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Do you have any type of allergy? If yes please specify from what?:
*
Do you have any chronic disease or medical problem?:
Diabetes
Hypertension
cholesterol
Blood Problem
Heart Disease
Thyroid
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Do you use any regular medication? If yes, please share the name?:
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Do you have a preferred time to be called during the day?:
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Do You have visa?:
Yes
No
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Upload passports front two pages.:
Upload clear photo with blue background and ears appearing.:
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Companion Name:
Relation with patient::
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Mother
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Sister
Upload companion's Visa application after filling out:
Upload companion's passports front two pages.:
Upload companion's clear photo with blue background and ears appearing.:
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