Contact Us

India Office

  • 7th Floor, Avanta Business Center,
    Silverton Tower, Nirvana Colony, Sector-50,
    Golf Course Extension Road,
    Gurgaon - 122018, Haryana, INDIA
  • Phone : +91.124.4751800
    Mobile : +91.9873002212,
    Mobile : +91.9871520336,
    Mobile : +91.9818994114.
  • email: info@globalcare-health.com


Kurdistan office

  • 6, Italian village, Erbil Kurdistan,
  • Mobile : +964 7508785856
    India mobile: +91 9910949412
  • email: kojeen.fortis@gmail.com


Afghanistan Office

  • Hayat Balkh hospital Mazare I sharif,,
    Afghanistan
  • Mobile: +93 788620230
    Mobile: +93 786007600>
    India mobile: + 9198-99-500888
  • email: info@globalcare-health.com



Patient Contact Information

Last Name: *
Email: * Phone: *
Mobile Phone    
Address # 1: Address # 2:
City: State:
Country:

Emergency Contact Information

Last Name: *
Email: * Phone: *
Address # 1: Address # 2:
City: State:
Country:

Requested Procedure

Please tell us which procedure you are interested in receiving:

Why are you interested in receiving the above procedure?

(Please be as honest as possible when responding to the above question - it is important that the doctor truly understands the purpose).

General Information/Statistics

Gender Height
Weight Date of Birth

Medical Conditions

Are you/have you ever had:

Aids or HIV +ive Yes No Anemia Yes No
Arthritis Yes No Asthma Yes No
Back Problems Yes No Blood Clots Yes No
Blood Disorders Yes No Bleeding Problems Yes No
Breathing Problems Yes No Cancer Yes No
Chest Pains Yes No Colitis Yes No
Depression Yes No Diabetes Yes No
Ear Problems Yes No Eye Problems Yes No
Epilepsy Yes No Heart Problems Yes No
Heart Murmur Yes No Hepatitis Yes No
High Blood Pressure Yes No Irregular Heartbeat Yes No
Kidney Problems Yes No Liver Problems Yes No
Migraine Headaches Yes No Nervous Breakdowns Yes No
Nose/Throat Problems Yes No Osteoporosis Yes No
Pneumonia Yes No Any psychiatric conditions Yes No
Rheumatic Fever Yes No Seizures Yes No
Shortness of Breath Yes No Skin Cancer Yes No
Stomach Problems Yes No Stroke Yes No
Thyroid Problems Yes No Tuberculosis Yes No
Transfusion Yes No    

For Women Only

Do you take birth control pills or any hormone replacement medication or patches? Yes No
Are you pregnant? Yes No
(Pregnant women must take a pregnancy test before departure as most pregnancies can disrupt surgery)

Medical History

In the past 18 months, have you been hospitalized, had surgery or received medical treatment, pregnancy delivery, or ambulatory surgery Yes No
What was your date of surgery?
What was your reason for surgery?
Have you ever had weight loss (bariatric) surgery? Yes No
Which procedure did you have?
What was your date of surgery?
What was your net weight change since surgery?
Do you have any implants or metal objects in your body? Yes No
A pacemaker? Yes No
Plates, screws or other hardware from other procedures? Yes No
Do you have difficulty with healing or scarring? Yes No
Have you had cosmetic surgery in the past? Yes No
If yes, please explain how your experience was:
Please list any other past surgeries:    

Medication

Kindly list all the medication you take, along with the dosage:
Are you allergic to any medication? Yes No
If yes, please explain which medication(s) along with the reaction(s)  
   
Have you had problems with anesthesia? Yes No
Are you allergic to any type of food or latex? Yes No
   
Do you take any vitamins or herbal supplements? Yes No
If yes, please explain which ones:  
       
Do you smoke? Yes No
If yes, how much do you smoke? Per day, per week, per month?
Do you drink alcohol? Yes No
If yes, how much? Per day, per week, per month?

Travel Information

What is your approximate date for your surgery? Month/Year
(Please provide an estimate so we can determine if the climate will affect your procedure)
Would you have problems with a 5 hour flight? Yes No
Would you have problems with a 10 hour flight? Yes No
Would you have problems with a 20 hour flight? Yes No
If yes, then would a stopover into another city to break the journey be helpful? Yes No
Do you have a valid passport? Yes No
If no, then would you require assistance in obtaining a valid passport? Yes No

Dental Information

Do you plan to get dental work done in conjunction with your other procedure(s)? Yes No
If yes, please tell us what dental procedure(s). If no, then skip this step.  
Crowns
Veneers Porcelain Composite
Standard Checkup
Fillings
Root Canal
Tooth Extraction(s)
Dentures, Bridge, or other dental prosthesis
Invisalign, linqual, or traditional braces

*If you are requesting Dental Procedures, please populate the below fields

Do your gums bleed when you brush? Yes No
Are your teeth sensitive to heat or cold? Yes No
Are your teeth sensitive to pressure? Yes No
Are your teeth sensitive to sweets? Yes No
Do you grind or clench your teeth? Yes No
Do you have any fear of dental work? Yes No
   
Date of last dental visit
What was done at the time?
Former Dentist Name
How do you feel about the appearance of your teeth
How would you describe your current dental problem?  
   

*If you are requesting Cosmetic Procedures, please populate the below fields

If you are requesting liposuction please state the specific area for procedure such as inner or outer thighs, stomach, neck etc:
If you are requesting breast surgery please state your bra size and what size you wish to be:
For breast implants do you want saline or silicone implants?
   
 
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