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Patient Admission Form
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Step 1
Name
Surname
Country
Age
Phone number in the home country
Phone number in Iran
E-mail
Passport Number
Please upload the scan of your passport here
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Step 2
Requested Services
Thoracic Surgery
Cardiac Surgery
Tracheal Stenosis
Sleep Test
Pet- scan
Tuberculosis ,MDR TB, XDR TB
Other( please describe)
Step 3
Past Medical History of patient
Summary of patient recent admit ion
laboratory Test Results
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Radiology (X-Ray)Scan
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