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Patient Form

Patient Form

You have questions-we would like to answer you. Please send us your message over this E-Mail-Formulary, We will call you back as soon as possible.

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Patient's First Name

Patient's Last Name

Gender

Male Female

Date of Birth(Day,Month,Year)

Permanent Address

Country

City

Zip or Postal Code

Mobile Phone

E-mail

Fax

Requested Hospital

Patient Symptom(s) / Diagnosis

Patient Clinical Status

Short History of the Disease

Anticipated Travel Dates to Turkey;

From

To

Hotel Accommodations

Yes No

Transportation from Airport to hotel or hospital

Yes No

Any Additional Info

How did you learn about Başkent University Healtcare Group? (check all that apply)

internet
treating physician/hospital
family members/friends
business partners
press releases
embassy/governmental institution
health insurance
Other

Enter Security Code

Patient Guide

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International Patient Center

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Medical Travel Process

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About Your Stay In BAŞKENT

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Administrative Assistance

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Financial Matters

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Get a Second Opinion

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Patient Rights

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Patient Satisfaction Survey

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Frequently Asked Questions

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Get in Contact

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Patient Form

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e-Brochure

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Baskent Universty Tourism & Organization (BUTO)