ALL Patient Registration

Patient Registration
The Syrian American Medical Society will conduct a medical mission in the Bekaa region during the month of May 2023, during which surgeries will be performed for selected patients. The following survey is for registering cases that require surgeries.

Important notice to patients: Filling out the following form does not mean or confirm the necessity of performing surgical procedures for any patient simply because they have filled out and registered the form. All cases will be presented to specialized doctors who will study the cases and select a portion of them for surgical procedures. Based on this, patients will be contacted.

This campaign does not include dental braces installation or even teeth implantation.
Date of Encounter*

DayMonthYear
Date
Country | Clinic*

Lebanon - CMF - (Hamed Farhat Hospital)Lebanon - Pediatric Dentistry (Chtoura Hospital)Lebanon - Dentistry - MAPS Medical
Name*

First NameLast Name
Gender*

MaleFemale
Date of Birth*

DayMonthYear
Date
Mobile Number*
Needed to contact you in case you were selected for surgery
Nationality*

LebaneseSyrianPalastinian - LebanesePalastinian - Syrian
Does the patient have any physical or mental disability?*

YesNo
Area of Residence (City / Town)*

Beirut and Mount LebanonAkkarTripoliBeqaaSouthOther
Surgical Specialty Need (Select More then One)*

Orthognathic Surgery (Lefort or mandible)TMJ Disease - Limited mouth openingCleft Palate SurgeryCleft Lip SurgeryFacial Jaw Tumors and CystsENTDermatologyPediatric Dentistry - OR (Special Need)Dental ClinicOrthodonticsOphthalmologyOther
Case Details / Reason for Referral
More details will help us prepare more for surgery
Major Medical History
Take / upload multiple picture of deformity

Cancelof
Upload Medical Report + Xrays + CT Scan

(Note: The presence of a clear medical report confirming the patient's need for a surgical operation among the following operations makes the patient's file more likely to be accepted by the medical committee.)
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Calculation
To be completed by Surgical / OR Team
Surgery Date

MonthDayYear
Date
Surgery Location

Lebanon - CMF - (Hamed Farhat Hospital)Lebanon - Pediatric Dentistry (Chtoura Hospital)
Operative Notes (SURGERY TEAM ONLY)
Projected Cost for the Surgery (SURGERY TEAM ONLY)
Pre-Op | Intra-Op | Post-OP Pictures (SURGERY TEAM ONLY)

(For Surgical Team ONLY)
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Should be Empty:

Patient Registration

To be completed by Surgical / OR Team