Feedback Form | TrustMed Clinic
Male
Female
Your Gender
Name Surname
Birthdate
Phone
Email
Weight (kg)
Height (cm)
Do you have any allergies? (Please specify)
Do you have a diagnosed disease?
Is there any medication you use regularly? (Please specify drug name and quantities)
Have you had surgery before? Please specify with dates
--Select--
No, I'm not pregnant
Yes, I'm pregnant
I have plans to get pregnant soon.
Are you currently pregnant? Or are you planning a pregnancy soon?
Have you ever given birth? If yes, when did you stop breastfeeding?
Do you smoke and drink alcohol? Please specify quantities
When do you plan to come for the operation?
No
Yes
Do you take narcotic substances?
Send
Göreviniz
