Milad Hospital || miladkhoy.com || Med form

Personal profile

Name*

Last name*

Gender*

male

female

father's name*

Marital status*

Married

single

Date of birth*

Contacts

Phone*

Mobile*

Emergency mobile number

Email*

Social Networks

Whatsapp*

Instagram

Facebook

Residence profile

birth country*

Current citizenship*

Previous citizenship*

Passport number

Passport type

Date of passport issuance

Country of issue of passport

Passport expiration date

Supplementary

Job

Company

Medical profile of the patient

Please explain about your illness and request *

If you have a history of the disease, name it

What bothers you the most? *

Date of request for face-to-face treatment *

Patient description and request *

Link to share medical records related to the disease

Send us your medical records about your illness in a zip file

How did you get to know us? *

If the form is sent correctly, you will be transferred to the main page

Online registration of patient admission requests