Tuberculosis Institute

Respiratory Health Institute

Respiratory Diseases Institute

 
Patient Admition Form
Name: *
Surname: *
Age:
Phone number in the home country:
Phone number in Iran:
Email:
Passport Number: *
Please upload the scan of your passport here   
Requested Services:
Thoracic Surgery
Cardiac Surgery
Tracheal Stenosis
SleepTest
Pet-Scan
Tuberculosis, MDR TB, XDR TB
Other
Past medical history of patient:
Summary of patient recent admition:
Laboratory test result:
Radiology (X-Ray) scan
Please insert the text below in to the text box
متن درون تصویر را در جعبه متن زیر وارد نمائید 
*
 
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