Medical Form

Name & surname(Required)

Age(Required)

Country and city of citizenship(Required)

Date of Birth(Required)

Weight(Required)

Height(Required)

Do you Smoke?(Required)

Number of Cigarettes per day?

Alcohol?(Required)

Amount?

Have you ever had any operation before, please state which operation you had and if there were any complications?(Required)

Do you have a contagious disease?(Required)

HIV? Hepatitis B? Hepatitis C?

Is there an abnormality you observe about wound healing?(Required)

Do you have an abnormality that you know about your bleeding clotting times, do you have an abnormal test result or do you have ANY illnesses?(Required)

Do you use ANY medication?(Required)

Do you have ANY allergies?(Required)

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Medical Form

Medical Form

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