CMF Patient Registration Jordan

Patient Registration - Jordan Jan 2024
The Syrian American Medical Society will conduct a medical mission in month of Jan 2024, 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*

Jordan - Zaatari ClinicJordan - Outside ZaatariOther
Name*

First NameLast Name
Gender*

MaleFemale
Mobile Number*
Needed to contact you in case you were selected for surgery
Date of Birth*

DayMonthYear
Date
Age*
Nationality*

JordanianSyrian
Does the patient have any physical or mental disability?*

YesNo
Area of Residence (City / Town)*

Provide me list please - by SAMS country office
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
Tell us about your medical problem. The more details you provide, the more likely your case will be selected in our committee. Please update Images (full face and close up, CT results, Dental xrays, Ct reports whatever you have available)
Case Details / Reason for Referral
More details will help us prepare more for surgery
Major Medical History
Take / upload multiple pictures of deformity

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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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To be completed by Surgical / OR Team

Completed only After Surgery is completed
Surgery Date

MonthDayYear
Date
Surgery Location

Jordan - CMF - Hospital 1Jordan - CMF - Hospital 2
Duration of Surgery (in Hours)
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 - Jordan Jan 2024

To be completed by Surgical / OR Team