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General Health Information (Please read and answer the questions in this section carefully! *)

Do you have any allergies to medication?

NoYes

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Have you ever had any serious illness in the past?

NoYes

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Do you regularly take any medications or supplements?

NoYes

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Have you undergone any surgeries in the past?

NoYes

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City You Want to Receive Treatment In
IstanbulAntalyaAnkaraIzmir--AdanaAdıyamanAfyonkarahisarAğrıAksarayAmasyaArdahanArtvinAydınBalıkesirBartınBatmanBayburtBilecikBingölBitlisBoluBurdurBursaÇanakkaleÇankırıÇorumDenizliDiyarbakırDüzceEdirneElazığErzincanErzurumEskişehirGaziantepGiresunGümüşhaneHakkâriHatayIğdırIspartaKahramanmaraşKarabükKaramanKarsKastamonuKayseriKilisKırıkkaleKırklareliKırşehirKocaeliKonyaKütahyaMalatyaManisaMardinMersinMuğlaMuşNevşehirNiğdeOrduOsmaniyeRizeSakaryaSamsunŞanlıurfaSiirtSinopSivasŞırnakTekirdağTokatTrabzonTunceliUşakVanYalovaYozgatZonguldak

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