International Patient Intake Form
Please provide your information below. Thank you!
Your Contact Information
Your full name
(ضروری)
Relationship to patient
(ضروری)
Your phone number
(ضروری)
Your email address
(ضروری)
Your primary language
(ضروری)
Brief description of your request
(ضروری)
Patient Information
Patient's name (last, first, middle)
(ضروری)
Patient's date of birth (month, day, year)
(ضروری)
MM slash DD slash YYYY
Patient's sex
(ضروری)
Female
Male
Permanent address
City, State/Province, Country
(ضروری)
Temporary/local address
(ضروری)
Temporary/local address city, state/province, country
(ضروری)
Patient's suspected diagnosis
Travel Companion Information
Patient Travel Companion #1
Full Name
(ضروری)
Phone number
(ضروری)
Relationship to patient
(ضروری)
Clinical Information
Referring physician name
Referring physician phone number
Referring physician email
Referring hospital name
Referring hospital address
Do you have medical images ready to share?
(ضروری)
Yes
No
? What are they
Please upload your medical records and imaging files here
حداکثر اندازه فایل: 50 MB.
Do you have recent medical reports translated into English?
Yes
No reports
I have reports but they are not in English
Payment Method (select from list)
(ضروری)
Insured
Government sponsored
Self-pay
Other
Patient Coordinator
Have you been in contact with one of our Patient Coordinators? (If yes, please specify who.)
Fatemeh Jokar BSN
No
Travel Information
When do you plan to travel to receive medical services at Ordibehesht Hospital?
(ضروری)
What country will you be traveling from?
(ضروری)
? How did you hear about us
Referring physician
Friend or Family member
Employer
News
Instagram
Online search
Ordibehesht Hospital Website
Other
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