Your name
Your phone number
Email
How old are you?
Do you have any chronic illness? (Such as heart disease and diabetes)
Do you use any medications regularly? (Such as insulin and anticoagulants)
Are you a smoker?
Are you addicted to any drug?
Do you have any allergies?
Have you had any surgery?
Do you have a genetic heart condition in your family?
Have you had local or general anaesthesia in the last 2 years?
Do you have/ had any contagious disease? (Such as Hepatitis A/B/C and HIV)
When would you like to have the operation? (optional)
Which country’s passport do you hold? Is it valid for at least 1 year?
Do you have a Turkish visa? If not, do you require an e-visa or an embassy visa?
Were you referred to us by someone? If yes, please provide their name or the source of the referral
Is there anything else you would like to add? (optional)
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