بیمارستان پارس

International Patient Department

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

* First Name:

* Surname:

* Date of birth:

* Email:

Telephone:

Fax:

Mobile:

* Country:

* Age:

Marital status:

Interpreter Required? No Yes

Language:

Have you been hospitalized recently? No Yes

Reason:

HowLong:

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, TehranIran 1415944911
	Phone: (021) 88960052
	Fax: (021) 88966052
	Info@ParsHospital.ir