Proficure Medical Inquiry Form

Name*

First NameLast Name

Email*

example@example.com

Phone Number

Please enter a valid phone number.

Age*

How old are you?

Sex*

Nationality

Health Insurance Status in Turkey*

SGK insuredPrivate health insurance with resident statusUninsuredOther

In this section you describe your medical complaint/issue/inquiry in detail.

What is your medical issue/ complaint?
Since when have you had this complaint?
Have you used any medication or other treatment for this issue?
What treatment are you looking for?
Do you have a specific diagnosis or are you looking for one?

What is your medical issue/complaint? Please describe in detail and answer all of the questions mentioned above.*

In this section we need information about your history of surgeries, previous medical diagnosis, regularly used medication, chronic diseases, allergies and family history of related conditions.

Have you had any surgeries before? If yes please provide detailed information and add reports in next section as well.*

Have ever had any other medical diagnosis?*

Do you have any chronic diseases (such as diabetes, hypertension etc.)*

Do you use any medication on regular basis. If yes, then please write the names and grammage as well.*

Do you have any family history of similar conditions/complaints that you are experiencing at the moment?*

Do you have any allergies? Please describe in detail.*

Please provide us with the latest diagnostic reports, images and case histories. It is important that you provide us with the most up to date information in-order to avoid unnecessary procedures and costs. The below mentioned documents are important for receiving an accurate diagnosis and should not be omitted.

Radiological Imaging Reports – If possible, the image itself should also be provided along with the report. MRI scans - CT scans - PET-CT scans - X-rays - Ultrasound Scans*

Biopsy / Pathology Reports Including diagnosis and Genetic test results

Blood Tests - The latest blood tests are usually sufficient