MaxxClinic- Online Information Form

Online Form EN

First Name

Middle Name

Last Name

Weight (kg)

Height (cm)

Date of Birth

Gender

Female

Male

I do not want to specify

How many times have you been pregnant?

How many times have you had a live birth?

Date of your last birth?

When did you stop breastfeeding?

Do you want to give birth in the future?

Nationality

Phone/Mobile

Have you had any surgery in the past?

Yes

If yes, which operation and when?

Do you have any chronic diseases? If yes, explain in detail.

Yes

You can select multiple options from the drop-down menu.

Please describe in detail your disease that is not listed.

Do you have an infectious disease? (Hepatitis, HIV, Tuberculosis, etc.)

Yes

If so, please explain in detail.

Do you take any medication regularly?

Yes

If yes, please list the drugs and doses.

Are you allergic to any medicines or substances?

Yes

If so, please explain in detail.

Do you drink alcohol?

Yes

Sometimes

Do you smoke?

Yes

Sometimes

Have you had the COVID-19 vaccine? (If your answer is yes, please select your vaccines below)

Vaccinated

Unvaccinated

1st Dose of COVID-19 Vaccine

2nd Dose of COVID-19 Vaccine

Will you be accompanied? (If yes, please fill in the information in the drop down box)

Yes, someone will be with me

No, I will come alone

Companion First Name

Companion Last Name

Companion Gender

Female

Male

I do not want to specify

Companion Nationality

Do you need accommodation? (If yes, please fill in the information in the drop down box)

Yes, I need accommodation

No, I don't need accommodation

Bed Choice

Double Bed

Two Single Beds

Requested Operation 1

Requested Operation 2

Requested Operation 3

Requested Operation 4

Is the date you are requesting the operation clear? (If yes, please fill in the information in the drop down box)

Yes, my operation date is certain

No, my operation date is not certain yet

Requested Operation Date

Payment Method

Cash

Credit Card

Information for cash payment

I know that US Dollars ($), EURO (€) and new British Pounds (£) are valid in Turkey, but old British Pounds are not. I will pay in US Dollars, Euros or new polymer British Pounds.

Information for payment by credit card

I understand that if I pay by credit card, I will be charged an additional 10% international transaction fee, and my bank may charge a commission of up to 8%, which has nothing to do with MaxxClinic.

If you have a special request, please explain.

I hereby declare that the particulars given above are correct and complete. I know that I may not be accepted for a surgical procedure by MaxxClinic due to incomplete or incorrect medical information I have stated above, and in this case I will not hold MaxxClinic responsible. I have been informed that my operation will not be performed if MaxxClinic doctors think that my surgery is not possible as a result of my medical imaging (X-Ray, USG, ECG etc.) examinations. I understand that I will have to pay extra if I need treatment that is not related to the treatments I have requested on this form (angiogram, myalgia, sore throat, cough, fever, flu, infection, intravenous vitamin-mineral supplement, MRI and CT, infectious diseases such as HIV-Hepatitis, etc.). I have read and agree to the Terms and Conditions and Privacy Policy