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دکتر علی میرصادقی _ Dr.Ali Mirsadeghi
مریم توانای فرهی _ Maryam Tavanaye Farrahi
About the Company
ADAK SALAMAT FARR KISH
Name and Surname :
*
Father's Name :
Gender :
Man
Female
Nationality :
date of birth (based on passport) :
Occupation :
Click or drag a file to this area to upload.
Occupation :
Type of Insurance :
Phone No. : (Home - Mobile)
Passport Number :
Address in the Country of Origin :
Patient Companion’s Information (profiler)
Name and Surname :
*
Passport Number :
Phone No. : (Home - Mobile)
Patient’s Medical History :
Chief Complaint :
Clinical Symptoms :
Patient’s Background :
Drug Dependence and the Like :
Consumed Drugs :
Possible Diagnosis (Opinion of Medial Dispatcher) :
Former Measures :
Appendices ( Send the files as a .zip file )
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Select Attachments to Submit
Ultrasound
MR
CTS
Radiology
Echocardiography
angiography
Stress test
Audiometry
Optometry
other (by recording the type of medical records)
Overall physical condition (be sure to mention any type of physical disability)
Corporate physician’s treatment plan: outpatient
outpatient
hospitalization
Name
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