ترجمه نوشته: Step 1 of 4 25% Patient profile(Required) Name Last name Please enter your personal details in the box above.Gender:(Required) Man Woman Please select your gender.National codePreferably, enter your national code in English.Date of birth(Required) YYYY slash MM slash DD Mobile phone(Required)Please enter your mobile phone number in the box.LandlinePlease enter your landline number in the box above.Residential address City State / Province / Region AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Please enter your residential address in the boxes above.Your email(Required) Please enter your email address in the box above. Medical records Drop files here or Select files Max. file size: 40 MB. If you have medical documents, please upload them in the box above.Which dental services do you need?(Required)Dental implantsDental restoration (film and filling)Dental laminates and crowns (full ceramic and ceramic)Orthodontics (Brackets and Lingual Orthodontics)Bleaching (teeth whitening)Tooth extraction (endodontics)Pediatric dentistryOral and maxillofacial surgeriesDental prosthesisDental and cosmetic servicesEndodontics (root canal treatment)Please select one of the above.Full explanation of the illness or health problem:Please enter a description of your illness.Tourism service package, Arvan health(Required)Economic health tourism packageStandard health tourism packageVIP Health Tourism PackageChoose one of the packages according to your travel budget. Has this problem been treated before? yes no Previous medical or surgical history:Please enter the information in the box above if you have medical records.Are you taking any specific medication? yes no If yes, enter the name of the medication and the dosage:What is your request and goal for treatment?Please write your goal of treatment and surgery in the box above. Do you have a specific date in mind for treatment? yes no If yes, enter your desired date: YYYY slash MM slash DD Do you have a history of allergies to medications or certain substances? yes no If yes, please explain:Do you have a history of certain diseases such as blood pressure, diabetes, etc.? yes no If yes, please explain:Do you need medical advice or specific information?(Required) yes no If yes, please explain:Have you read and agree to our terms and conditions? yes no Would you like to be informed about future services and treatments via email and SMS?(Required) yes no
