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Medical Information
Have you ever given birth?
Do you have HIV?
Do you have hepatitis B?
Do you have hepatitis C?
Do you have any other infectious diseases?
Have you ever experienced the following situations?
Chest Pain
Breast Disease
Have you ever had a seizure?
Heart Murmur
Thyroid Disorder
Scar Problem
Hypertension
Anemia
Diabetes
Cancer
Asthma
Dry Eye Syndrome
Bleeding disorders
Do you have any other chronic diseases?
Do you take any medications daily or frequently? (Including aspirin and over-the-counter medications)
Have you had any surgery before?
Do you have any allergies? (including latex)
Do you use contraceptives?
Do you smoke?
Do you drink alcohol?
Do you drink energy drinks?
Do you take any vitamins or supplements? (especially Ginkgo, Ginger, Garlic, St. John's Wort, Vitamin C, Vitamin E, Fish oils)
Do you use any drugs? *It is vital to answer this question honestly!
Do you have any psychological disorders such as anxiety or depression?
Have you or your family member experienced any problems during general anesthesia?
Could you write down the names and phone numbers of two people you know whom we can reach in case of emergency?
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  • Please, Write a valid Phone Number!
Fill out the contact form for detailed information.
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