A GLOBAL WORLD MEDICAL HEALTH TOURISM CONFERENCE

A TRULY ASIAN EXPERIENCE 2010

Make An Appointment

Patient’s Details

To facilitate your appointment request, please completely fill-out the form for pre-registration purposes.

Preferred Destination: Preferred Facility: Preferred Doctor: Date of Arrival and Time: Preferred Date & Time of Visit: Preferred Hotel: Personal Data: Full Name: Marital Status Date of Birth: Age: Occupation: Nationality: Passport Number: Height: Body Weight: Mailing Address: Home Phone Number: Cell Phone Number: *E-mail Address: Person to be contacted in case of emergency: Relationship: Medical Data: Reason for Referral/Chief Complaints: History of any allergies (food? medications?):
History of any medical problems:
Previous surgery and approximate dates:
Are you currently taking any prescribed drugs (including aspirin, vitamins, herbals, chinese medicines, etc.)?
Yes  No
Do you ever have prolonged bleeding or easy bruising?
Yes  No
Keloids / Raised Scars?
Yes  No
Are you a smoker?
Yes  No
How many sticks a day? Do you drink alcohol regularly?
Yes  No
Have you ever had jaundice (skin yellowing)?
Yes  No
Swelling of the ankles or legs?
Yes  No
Any family history of chronic diseases, like diabetes, hypertension, cancer, etc.? Please list:
Have you ever been under the care of a psychiatrist or clinical psychologist?
Yes  No
Is there anything else that your doctor should know about your medical history?
For Women:Number of Pregnancies: Number of Deliveries:

Consent To share Medical Information

I understand that my medical information is confidential and will only be shared as necessary with other medical personnels involve in my care and/or with my insurance company. I hereby authorize release of my medical information when the circumstances warrants it and for all physicians/ healthcare providers, past and present to discuss my medical history and release my medical records to my attending medical specialist. Furthermore, I agree to receive treatment or a procedure which is mutually agreed upon by me and my physician.

*Patient's Name: *Date: *
Please check if you agree to share information. Your actual signature will be ask upon arrival.

Consent to share photographs:

I understand that photographs are a valuable part of planning and documention of my care. I consent for photographs to be taken during my evaluation, recovery and surgery. These photographs and the medical records created in my case, may be used to communicate with other physicians, or if applicable, with insurance companies for professional consultations, educational or reimbursement purposes.

*Patient's Name: *Date: *
Please check if you agree to share information. Your actual signature will be ask upon arrival.