Description of the disease
When do you plan to travel for treatment?
Contact Information
Personal data
Briefly describe your problem and ask your questions - so that the doctor can develop a more relevant treatment program
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How long do you plan to travel for treatment?
I do not wish to travel for treatmentWithin a month from nowfrom one to two monthsfrom two months to 6 monthsmore than 6 months
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Please fill in the patient's personal data,
name and nickname sex MaleFemale Age: Nationality: country of residence
