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Name Surname*

Phone Number*

Date Of Birth

Your Adress?

E-Mail*

Your height in centimetres?

Your weight in kg?

Your blood type?

Have you ever given birth? If yes, which year?

Do you have any contagious diseases? If yes, please explain the details.

Have you ever been tested positive for Covid-19?

Past Medical History that needs mention?

Do you have any chronic diseases? If yes, please explain the details.

Do you use any medication daily or often? If yes, please explain the details.

Have you ever had any surgeries before? If yes, please write down what procedure and when it was

Do you have any allergies? If yes, please give details

Do you use contraceptives? (Birth control method)

Do you smoke?

Do you use alcohol?

Do you drink energy drinks?

Do you use vitamin or food supplements?

Do you use soft or hard drugs? (Answering this questions honestly, has vital importance!)

Do you have psychological problems such as anxiety or depression?

Have you or your family ever had difficulties with General Anesthetic?

Emergency contact person name and phone

I have read the KVKK Clarification Text, I Accept.

I would like to receive electronic messages within the scope of the Open Consent Text in order to be informed about important campaigns.