Pars Hospital

International Patient Registration

Please complete and return admission form, patient history and Follow Up to Pars hospital.

Personal Information

* First Name

* Surname

* Date of Birth

* Email

Telephone

Fax

Mobile

* Country

* Age

Marital Status

Service Language

Interpreter Required?

No Yes

Language

Hospital Information

Have you been hospitalized recently?

No Yes

Reason

How Long

Medical Information

Reason for this admission and history of present illness Medical and surgical history: List the medical condition / operations performed and date

Current Medications Please list all medications including complementary medications and bring these to hospital in their original containers. Please fill out the blank by this format: Drug Name - Dose - Frequency / Time

* FollowUp Please Write Your Problem OR any Medical Question

	Pars Hospital 67 Keshavarz Blvd, Tehran, Iran 1415944911
	(021) 88960052
	(021) 88966052 : Fax
	info@ParsHospital.ir