Description of the disease When do you plan to travel for treatment? Contact Information Personal data Description of the disease Briefly describe your case and ask your questions – so that the doctor will draw up a more relevant treatment program Next When to start treatment What is the period of time you plan to travel for treatment? I do not want to travel for treatmentWithin a month from nowFrom one to two monthsFrom two to six monthsMore than 6 months FirstPrevious Next Contact Information Please fill in the following information correctly to be contacted Phone Number: E-mail: FirstPrevious Next Personal data Please fill in the patient’s personal data Name and Surname: Gender: MaleFemale Age: Nationality: Residence country: FirstPrevious Description of the disease When do you plan to travel for treatment? Contact Information Personal data Description of the disease Briefly describe your case and ask your questions – so that the doctor will draw up a more relevant treatment program Next When to start treatment What is the period of time you plan to travel for treatment? I do not want to travel for treatmentWithin a month from nowFrom one to two monthsFrom two to six monthsMore than 6 months FirstPrevious Next Contact Information Please fill in the following information correctly to be contacted Phone Number: E-mail: FirstPrevious Next Personal data Please fill in the patient’s personal data Name and Surname: Gender: MaleFemale Age: Nationality: Residence country: FirstPrevious
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