Randevu Talep - Doktor Burak Ayyıldız

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Randevu Talep

Burak Ayyıldız Randevu Talep Formu

Hemen Randevu Talep Edin

Formdaki tüm alanları doldurunuz. Sorulara cevabınız evet ise lütfen durumu açıklayınız.

Adınız Soyadınız

Telefon

Yaş

Cinsiyet

Doğum Yeri

Meslek Bilgisi

Medeni Durumu

Çocuk Sayısı

Boy

Kilo

Düzenli̇ İlaç Kullandığınız Kronik Hastalıklarınızı Belirtiniz

Geçi̇rmi̇ş Olduğunuz Ameli̇yatlar Varsa Beli̇rti̇ni̇z (Doğum Dahi̇l Yapilan Tüm Müdahaleleri̇ İçeri̇r)

Geçi̇rmi̇ş Olduğununuz Kazalar Varsa Beli̇rti̇ni̇z (İş Kazalari Trafi̇k Kazasi Vb.)

Anne Baba Veya Çocuklarinizda Sürekli̇ İlaç Kullanimini Gerekti̇ren Veya Sakatlik Oluşturan Durumlar Varsa Beli̇rti̇ni̇z

Akti̇f Şi̇kayet Veya Şi̇kayetleri̇ni̇zi̇ Başlangiç Süreleri̇ İle Beli̇rti̇ni̇z

Bu Şi̇kayetleri̇ni̇ze Yöneli̇k Gi̇tti̇ği̇ni̇z Heki̇mleri̇ Ve Aldiğiniz Tedavi̇leri̇ Beli̇rti̇ni̇z

Şi̇kayet Dışı Başvuru Sebebi̇ni̇z Beli̇rti̇ni̇z (Si̇gara Bağımlılığı, Sağlıklı Yaşam Danışmanlığı, Kilo Kontrolü Vb.)

Hali̇ Hazırda Kullandığınız İlaçları Ve Gıda Takvi̇yeleri̇ni̇ Beli̇rti̇ni̇z (Vi̇tami̇nler Yağlar Vb.)

ÖZELLİKLE BAŞVURU YAPTIGINIZ ALAN VARSA BELİRTİNİZ

Adınız Soyadınız

Tel

Yaş

Cinsiyet

Doğum Yeri

Meslek Bilgisi

Medeni Durumu

Çocuk Sayısı

Boy

Kilo

Düzenli̇ İlaç Kullandığınız Kronik Hastalıklarınızı Belirtiniz

Geçi̇rmi̇ş Olduğunuz Ameli̇yatlar Varsa Beli̇rti̇ni̇z (Doğum Dahi̇l Yapilan Tüm Müdahaleleri̇ İçeri̇r)

Geçi̇rmi̇ş Olduğununuz Kazalar Varsa Beli̇rti̇ni̇z (İş Kazalari Trafi̇k Kazasi Vb.)

Anne Baba Veya Çocuklarinizda Sürekli̇ İlaç Kullanimini Gerekti̇ren Veya Sakatlik Oluşturan Durumlar Varsa Beli̇rti̇ni̇z

Akti̇f Şi̇kayet Veya Şi̇kayetleri̇ni̇zi̇ Başlangiç Süreleri̇ İle Beli̇rti̇ni̇z

Bu Şi̇kayetleri̇ni̇ze Yöneli̇k Gi̇tti̇ği̇ni̇z Heki̇mleri̇ Ve Aldiğiniz Tedavi̇leri̇ Beli̇rti̇ni̇z

Şi̇kayet Dışı Başvuru Sebebi̇ni̇z Beli̇rti̇ni̇z (Si̇gara Bağımlılığı, Sağlıklı Yaşam Danışmanlığı, Kilo Kontrolü Vb.)

Hali̇ Hazırda Kullandığınız İlaçları Ve Gıda Takvi̇yeleri̇ni̇ Beli̇rti̇ni̇z (Vi̇tami̇nler Yağlar Vb.)

ÖZELLİKLE BAŞVURU YAPTIGINIZ ALAN VARSA BELİRTİNİZ

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