PATIENT REFERRAL FORM

  
1. Who recommended our services to you?
Relative / acquaintance / friend
Insurance company
Governmental Institute
Embassy
Employer
Other, please specify             :

2.
Please check one:
Self-Referral
Insurance company
Governmental Institute

Referral request:
2nd Opinion
Physician Consultation
Hospital Admission
Cost Analysis
 

3.
Do you have a preference for one of the following hospitals:
BUHN Ankara Central Hospital
BUHN Adana Yüreðir Hospital / Teaching & Medical Research Center
BUHN Alanya Teaching & Medical Research Center
BUHN Konya Teaching & Medical Research Center
BUHN Izmir Teaching & Medical Research Center
BUHN Istanbul Cardiology and Cardiovascular Surgery Center
BUHN Adana Oncology and Radiotherapy Center
BUHN Faculty of Dentistry Diagnosis and Treatment Center
No Preference
 
 

4.
Patient Information

Patient's Name (Required)                : 

Patient's Family Name (Required)   : 

Gender (Required)                              :  Male      Female

Date of Birth (Month, Day, Year)        : 

Permanent Address (Required) :


City (Required) :


Country (Required) :


Zip or Postal Code:


Home Telephone: (Required) 


Business Telephone:


E-mail (Required) :


Fax:


Local Address in Turkey (if available):


Local Telephone (if available):


Local Fax (if available):


Emergency Contact Name:


Contact’s Relation to Patient:


Contact’s Telephone Number:
 
 

5.
Clinical Information

Patient Diagnosis (please list all of your diagnoses):


Patient Clinical Status:


Involved Clinical Department / ’s or Specialty / ’s


Special Request Regarding Diagnosis or Treatment


Special Consideration or Question Regarding Diagnosis or Treatment


Business Telephone:


E-mail (Required) :


Fax:


Local Address in Turkey (if available):


Anticipated Travel Dates to Turkey: From:  to

Referring Physician Name (Required):


Affiliation:


Office Telephone Number:


Fax Number


Emergency Telephone Number


E-mail Address
 
 

6.
Patient Services Information
Will you need assistance with the following?

Interpreter Services:        Yes     No

Languages you speak


Interpreter Services:        Private Room    Semi-private room (2 or more beds)

Hotel Accommodations: Yes     No

Number of guests traveling with you :


Number of hotel rooms needed :


Hotel rating preference : Smoking   No Smoking

Transportation from Airport to hotel or hospital:  Yes     No

Special diet during your hospital stay:                   Yes     No

If yes, please specify diet :

 
 
Note: For self-pay patients requiring hospitalization, payment in advance is required. For some insurers and for embassy cases, we accept letters of guarantee in place of advance payment. If available, please send a detailed clinical summary along with this form.		  
 
PLEASE BE SURE TO REVIEW YOUR SELECTIONS CAREFULLY PRIOR TO SUBMISSION TO BUHN. WE LOOK FORWARD TO ASSISTING YOU, AND ASK THAT YOU PROVIDE AS MUCH OF THE REQUESTED INFORMATION AS POSSIBLE SO THAT WE MAY SERVE YOU BETTER.