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Home / BUHN ID Card Reðistration

BUHN ID CARD REGISTRATION

BUHN ID CARD REGISTRATION

Patient's Name (Required)               :

Patient's Family Name (Required)  :

Gender (Required)                              : Male      Female

Date of Birth (Month, Day, Year)        :

Permanent Mailing Address (Required):

City (Required):

State / Province:

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):

What is your insurance status:
Not insured, paying everything by myself
National governmental insurance system with international coverage
National governmental insurance sytem without international coverage
Private regional health insurance company, without international coverage
Private regional health insurance company, with international coverage
Private worldwide health insurance company
The institution I’m working for is covering every kind of health costs
Other (please specify!):

Have you ever traveled to a foreighn country for health reasons?    Yes   No

If yes, please specify:

What were your major compliants regarding this?

Is there a special health care concern of yours:      Yes No

If yes, please specify:

What is your prior interest at the BUHN:
Finding a doctor
Getting a second oppinion
Other (please specify!)

Fields of Intrerest (please check at least one item):
Provide me with regular information on scientific activities at BUHN
Send me information on latest advances of medical interventions at BUHN
Add me to your regular mailing list
Inform me about special health tourism offers
Inform me about special spa tourism opportunities
Send me brochures, CD’s and/or cathalogs of your facilities