Patient Name Surname
Address
Telephone Number
E-mail Address
Date of Birthday
Present Dialysis Center
Dialysis Centre Telephone no
Doctor Name
Insurance Company
Date You wish to attend for dialysis
Days You wish to attend for dialysis
Prefferred times for dialysis 0800 13:00 18:00
Any Blood Diseases?  
Hbs Ag + -    AHbs + -    HCU + -    HCURNA + -
   
 

 

 
1993 - 2004 @ AHU HETMAN HOSPITAL
167. Sok. No:3 48700 Marmaris / TURKEY
Tel : +90 252 417 77 77 Fax : +90 252 417 00 40

info@ahuhetmandialysis.com