INSURED PERSON’S NAME, SURNAME: / DATE OF BIRTH / SEX:
CARD / POLICY NO: / APPLICATION DATE:
MEDICAL INSTITUTION’S NAME:
1. COMPLAINT(S) OF INSURED PERSON:
2. FIRST OCCURING DATE OF THE COMPLAINT(S):
……….DAY,………MONTH,………YEAR
3. PHYSICAL EXAMINATION RESULTS:
4. THE PREVIOUS EXAMINATIONS AND/OR TREATMENT DUE TO THIS (THESE) COMPLAINTS AND/OR THE SAME ILLNESS, THE RESULTS AND THE HEALTH INSTITUTION IN WHICH TREATMENT DONE.
5. BRIEF HISTORY OF INSURED PERSON: (The prior operations, illnesses, drugs used, habits etc.)
6.BRIEF HISTORY OF HIS (HER) FAMILY: / 7.PRIOR DIAGNOSIS:
8.DIAGNOSIS: / 9.TREATMENT:
10.THE MEDICAL EXAMINATIONS NEEDED::
THE INSURED’S DECLARATION:
The information I gave above is complete and right. The insurer has the right to want supplement information about this complaint:
INSURED PERSON’S NAME, SURNAME
DATE:
SIGNATURE: / DOCTOR’S NAME, SURNAME:
THE BRANCH OF THE DOCTOR:
As a doctor, I undertake that the information about the patient is right.
DOCTOR’S SEAL AND SIGNATURE:
“DR. EXAMINATION COPY” IS TO BE SENT TO OUR COMPANY WITH THE INVOICE.
“LABORATORY/RADYOLOGY COPY” IS TO BE AFFIXED TO THE “DR. DEMAND PAPER” IN CASE INSURED PERSON HAS HIS/HER MEDICAL EXAMINATIONS PREPARED IN A DIFFERENT MEDICAL INSTITUTION.
“PHARMACY COPY” IS TO BE AFFIXED TO THE PRESCRIPTION IN CASE THERE IS PRESCRIPTION.
THIS FORM IS TO BE FILLED OUT COMPLETELY BY THE DOCTOR ACCORDING TO THE INFORMATION THAT THE PATIENT DECLARED, THE RESULTS OF THE VİSİTS, THE INFORMATIONS IN THE POLYCLINIC REGISTRATIONS AND IS TO BE SENT TO OUR COMPANY WITH THE INVOICE, THE ACQUITTANCE AND DETAILED EXAMINATION RESULTS.INSURED PERSON’S NAME, SURNAME: / DATE OF BIRTH / SEX:
CARD / POLICY NO: / APPLICATION DATE:
MEDICAL INSTITUTION’S NAME:
1. COMPLAINT(S) OF INSURED PERSON:
2. FIRST OCCURING DATE OF THE COMPLAINT(S):
……….DAY,………MONTH,………YEAR
3. PHYSICAL EXAMINATION RESULTS:
4. THE PREVIOUS EXAMINATIONS AND/OR TREATMENT DUE TO THIS (THESE) COMPLAINTS AND/OR THE SAME ILLNESS, THE RESULTS AND THE HEALTH INSTITUTION IN WHICH TREATMENT DONE.
5. BRIEF HISTORY OF INSURED PERSON: (The prior operations, illnesses, drugs used, habits etc.)
6.BRIEF HISTORY OF HIS (HER) FAMILY: / 7.PRIOR DIAGNOSIS:
8.DIAGNOSIS: / 9.TREATMENT:
10.THE MEDICAL EXAMINATIONS NEEDED::
THE INSURED’S DECLARATION:
The information I gave above is complete and right. The insurer has the right to want supplement information about this complaint:
INSURED PERSON’S NAME, SURNAME
DATE:
SIGNATURE: / DOCTOR’S NAME, SURNAME:
THE BRANCH OF THE DOCTOR:
As a doctor, I undertake that the information about the patient is right.
DOCTOR’S SEAL AND SIGNATURE:
“DR. EXAMINATION COPY” IS TO BE SENT TO OUR COMPANY WITH THE INVOICE.
“LABORATORY/RADYOLOGY COPY” IS TO BE AFFIXED TO THE “DR. DEMAND PAPER” IN CASE INSURED PERSON HAS HIS/HER MEDICAL EXAMINATIONS PREPARED IN A DIFFERENT MEDICAL INSTITUTION.
“PHARMACY COPY” IS TO BE AFFIXED TO THE PRESCRIPTION IN CASE THERE IS PRESCRIPTION.
THIS FORM IS TO BE FILLED OUT COMPLETELY BY THE DOCTOR ACCORDING TO THE INFORMATION THAT THE PATIENT DECLARED, THE RESULTS OF THE VİSİTS, THE INFORMATIONS IN THE POLYCLINIC REGISTRATIONS AND IS TO BE SENT TO OUR COMPANY WITH THE INVOICE, THE ACQUITTANCE AND DETAILED EXAMINATION RESULTS.INSURED PERSON’S NAME, SURNAME: / DATE OF BIRTH / SEX:
CARD / POLICY NO: / APPLICATION DATE:
MEDICAL INSTITUTION’S NAME:
1. COMPLAINT(S) OF INSURED PERSON:
2. FIRST OCCURING DATE OF THE COMPLAINT(S):
……….DAY,………MONTH,………YEAR
3. PHYSICAL EXAMINATION RESULTS:
4. THE PREVIOUS EXAMINATIONS AND/OR TREATMENT DUE TO THIS (THESE) COMPLAINTS AND/OR THE SAME ILLNESS, THE RESULTS AND THE HEALTH INSTITUTION IN WHICH TREATMENT DONE.
5. BRIEF HISTORY OF INSURED PERSON: (The prior operations, illnesses, drugs used, habits etc.)
6.BRIEF HISTORY OF HIS (HER) FAMILY: / 7.PRIOR DIAGNOSIS:
8.DIAGNOSIS: / 9.TREATMENT:
10.THE MEDICAL EXAMINATIONS NEEDED::
THE INSURED’S DECLARATION:
The information I gave above is complete and right. The insurer has the right to want supplement information about this complaint:
INSURED PERSON’S NAME, SURNAME
DATE:
SIGNATURE: / DOCTOR’S NAME, SURNAME:
THE BRANCH OF THE DOCTOR:
As a doctor, I undertake that the information about the patient is right.
DOCTOR’S SEAL AND SIGNATURE:
“DR. EXAMINATION COPY” IS TO BE SENT TO OUR COMPANY WITH THE INVOICE.
“LABORATORY/RADYOLOGY COPY” IS TO BE AFFIXED TO THE “DR. DEMAND PAPER” IN CASE INSURED PERSON HAS HIS/HER MEDICAL EXAMINATIONS PREPARED IN A DIFFERENT MEDICAL INSTITUTION.
“PHARMACY COPY” IS TO BE AFFIXED TO THE PRESCRIPTION IN CASE THERE IS PRESCRIPTION.