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Name :

Age:

Phone:

National ID:

Physician:

E-mail:

- GenderMaleFemaleChild

- Booking TypeNormal BookingHome Visit

- Booking Date

- Which BranchTantaMehalla

What are pathological symptoms experienced by the patient?

- fasting YesNo

- Number of hours of fasting:

- Are you take the treatment for sugar?YesNo

- Treatment Name:

- Do you take treatment of blood thinners?YesNo

- Treatment Name:

- Do you take treatment of glands?YesNo

- Treatment Name:

- Do you take an antibiotic?YesNo

- Treatment Name:

- Have you ever blood transfusion?YesNo

- For women Is there a pregnancy?YesNo

- What is the deadline LMP:

- Does ovulation stimulants taken?YesNo

- In the case of measuring the quantity of the drug in the blood?YesNo

- Have you ever analysis by our labs?YesNo

- What are the required analyzes?