{"id":2377,"date":"2025-07-28T09:59:27","date_gmt":"2025-07-28T09:59:27","guid":{"rendered":"https:\/\/medcoordinate.com\/?page_id=2377"},"modified":"2025-09-25T22:35:47","modified_gmt":"2025-09-25T22:35:47","slug":"patient-medical-history-form","status":"publish","type":"page","link":"https:\/\/medcoordinate.com\/en\/patient-medical-history-form\/","title":{"rendered":"Patient Medical History Form"},"content":{"rendered":"<div data-elementor-type=\"wp-page\" data-elementor-id=\"2377\" class=\"elementor elementor-2377\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-bc4d53a e-flex e-con-boxed e-con e-parent\" data-id=\"bc4d53a\" data-element_type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d0f6d75 elementor-widget__width-initial elementor-widget elementor-widget-image\" data-id=\"d0f6d75\" data-element_type=\"widget\" data-widget_type=\"image.default\">\n\t\t\t\t<div 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id=\"wpforms-css-vars-elementor-widget-d63230e\">\n\t\t\t\t.elementor-widget-wpforms.elementor-element-d63230e {\n\t\t\t\t--wpforms-field-size-input-height: 43px;\n--wpforms-field-size-input-spacing: 15px;\n--wpforms-field-size-font-size: 16px;\n--wpforms-field-size-line-height: 19px;\n--wpforms-field-size-padding-h: 14px;\n--wpforms-field-size-checkbox-size: 16px;\n--wpforms-field-size-sublabel-spacing: 5px;\n--wpforms-field-size-icon-size: 1;\n--wpforms-label-size-font-size: 16px;\n--wpforms-label-size-line-height: 19px;\n--wpforms-label-size-sublabel-font-size: 14px;\n--wpforms-label-size-sublabel-line-height: 17px;\n--wpforms-button-size-font-size: 17px;\n--wpforms-button-size-height: 41px;\n--wpforms-button-size-padding-h: 15px;\n--wpforms-button-size-margin-top: 10px;\n\n\t\t\t}\n\t\t\t<\/style><div class=\"wpforms-container wpforms-container-full wpforms-render-modern\" id=\"wpforms-2356\"><form id=\"wpforms-form-2356\" class=\"wpforms-validate wpforms-form wpforms-ajax-form\" data-formid=\"2356\" method=\"post\" enctype=\"multipart\/form-data\" action=\"\/en\/wp-json\/wp\/v2\/pages\/2377\" data-token=\"17560b4f6ce39f82e56e3b86b311028f\" data-token-time=\"1780541494\" data-trp-original-action=\"\/en\/wp-json\/wp\/v2\/pages\/2377\"><div class=\"wpforms-head-container\"><\/div><noscript class=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/noscript><div class=\"wpforms-hidden\" id=\"wpforms-error-noscript\">Please enable JavaScript in your browser to complete this form.<\/div><div class=\"wpforms-field-container\"><div id=\"wpforms-2356-field_112-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"112\"><h3 id=\"wpforms-2356-field_112\" aria-errormessage=\"wpforms-2356-field_112-error\"> \u0634\u0631\u0643\u0629 \u0627\u0644\u062a\u0646\u0633\u064a\u0642 \u0648\u0627\u0644\u062a\u0646\u0638\u064a\u0645 \u0644\u0644\u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0637\u0628\u064a\u0629 - \u0627\u0644\u0633\u064a\u0627\u062d\u0629 \u0627\u0644\u0639\u0644\u0627\u062c\u064a\u0629  | Coordinate For Medical Tourism<\/h3><\/div><div id=\"wpforms-2356-field_105-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"105\"><h3 id=\"wpforms-2356-field_105\" aria-errormessage=\"wpforms-2356-field_105-error\">Patient Medical History Form Power of attorney and declaration of consent <\/h3><\/div><div id=\"wpforms-2356-field_77-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"77\"><h3 id=\"wpforms-2356-field_77\" aria-errormessage=\"wpforms-2356-field_77-error\">Patient information<\/h3><\/div><div id=\"wpforms-2356-field_111-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"111\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_111\"> \u0627\u0633\u0645 \u0627\u0644\u0645\u0631\u064a\u0636 | Patient Name  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2356-field_111\" class=\"wpforms-field-large wpforms-field-required\" name=\"wpforms[fields][111]\" placeholder=\"  Please enter your name in English  | \u0643\u062a\u0627\u0628\u0629 \u0627\u0644\u0627\u0633\u0645 \u0628\u0627\u0644\u0644\u063a\u0629 \u0627\u0644\u0627\u0646\u062c\u0644\u064a\u0632\u064a\u0629\" aria-errormessage=\"wpforms-2356-field_111-error\" required><\/div><div id=\"wpforms-2356-field_37-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"37\"><fieldset><legend class=\"wpforms-field-label\">  \u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0645\u064a\u0644\u0627\u062f | Date of Birth <\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-small\"><select name=\"wpforms[fields][37][date][d]\" id=\"wpforms-2356-field_37-day\" class=\"wpforms-field-date-time-date-day\" aria-label=\"Day\" ><option value=\"\" class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][37][date][m]\" id=\"wpforms-2356-field_37-month\" class=\"wpforms-field-date-time-date-month\" aria-label=\"Month\" ><option value=\"\" class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][37][date][y]\" id=\"wpforms-2356-field_37-year\" class=\"wpforms-field-date-time-date-year\" aria-label=\"Year\" ><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/fieldset><\/div><div id=\"wpforms-2356-field_46-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"46\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_46\">\u0627\u0644\u062c\u0646\u0633\u064a\u0629 | Nationality<\/label><select id=\"wpforms-2356-field_46\" class=\"wpforms-field-small\" name=\"wpforms[fields][46]\"><option value=\"\" class=\"placeholder\" disabled selected='selected'> Select Country | \u0627\u062e\u062a\u0631 \u0627\u0644\u062f\u0648\u0644\u0629<\/option><option value=\"Saudi Arabia\" >Saudi Arabia<\/option><option value=\"Afghanistan\" >Afghanistan<\/option><option value=\"Albania\" >Albania<\/option><option value=\"Mauritania\" >Mauritania<\/option><option value=\"Algeria\" >Algeria<\/option><option value=\"American Samoa\" >American Samoa<\/option><option value=\"Andorra\" >Andorra<\/option><option value=\"Angola\" >Angola<\/option><option value=\"Anguilla\" >Anguilla<\/option><option value=\"Antarctica\" >Antarctica<\/option><option value=\"Antigua and Barbuda\" >Antigua and Barbuda<\/option><option value=\"Argentina\" >Argentina<\/option><option value=\"Armenia\" >Armenia<\/option><option value=\"Aruba\" >Aruba<\/option><option value=\"Australia\" >Australia<\/option><option value=\"Austria\" >Austria<\/option><option value=\"Azerbaijan\" >Azerbaijan<\/option><option value=\"Bahamas\" >Bahamas<\/option><option value=\"Bahrain\" >Bahrain<\/option><option value=\"Bangladesh\" >Bangladesh<\/option><option value=\"Barbados\" >Barbados<\/option><option value=\"Belarus\" >Belarus<\/option><option value=\"Belgium\" >Belgium<\/option><option value=\"Belize\" >Belize<\/option><option value=\"Benin\" >Benin<\/option><option value=\"Bermuda\" >Bermuda<\/option><option value=\"Bhutan\" >Bhutan<\/option><option value=\"Bolivia (Plurinational State of)\" >Bolivia (Plurinational State of)<\/option><option value=\"Bonaire, Saint Eustatius and Saba\" >Bonaire, Saint Eustatius and Saba<\/option><option value=\"Bosnia and Herzegovina\" >Bosnia and Herzegovina<\/option><option value=\"Botswana\" >Botswana<\/option><option value=\"Bouvet Island\" >Bouvet Island<\/option><option value=\"Brazil\" >Brazil<\/option><option value=\"British Indian Ocean Territory\" >British Indian Ocean Territory<\/option><option value=\"Brunei Darussalam\" >Brunei Darussalam<\/option><option value=\"Bulgaria\" >Bulgaria<\/option><option value=\"Burkina Faso\" >Burkina Faso<\/option><option value=\"Burundi\" >Burundi<\/option><option value=\"Cabo Verde\" >Cabo Verde<\/option><option value=\"Cambodia\" >Cambodia<\/option><option value=\"Cameroon\" >Cameroon<\/option><option value=\"Canada\" >Canada<\/option><option value=\"Cayman Islands\" >Cayman Islands<\/option><option value=\"Central African Republic\" >Central African Republic<\/option><option value=\"Chad\" >Chad<\/option><option value=\"Chile\" >Chile<\/option><option value=\"China\" >China<\/option><option value=\"Christmas Island\" >Christmas Island<\/option><option value=\"Cocos (Keeling) Islands\" >Cocos (Keeling) Islands<\/option><option value=\"Colombia\" >Colombia<\/option><option value=\"Comoros\" >Comoros<\/option><option value=\"Congo\" >Congo<\/option><option value=\"Congo (Democratic Republic of the)\" >Congo (Democratic Republic of the)<\/option><option value=\"Cook Islands\" >Cook Islands<\/option><option value=\"Costa Rica\" >Costa Rica<\/option><option value=\"Croatia\" >Croatia<\/option><option value=\"Cuba\" >Cuba<\/option><option value=\"Cura\u00e7ao\" >Cura\u00e7ao<\/option><option value=\"Cyprus\" >Cyprus<\/option><option value=\"Czech Republic\" >Czech Republic<\/option><option value=\"C\u00f4te d&#039;Ivoire\" >C\u00f4te d&#039;Ivoire<\/option><option value=\"Denmark\" >Denmark<\/option><option value=\"Djibouti\" >Djibouti<\/option><option value=\"Dominica\" >Dominica<\/option><option value=\"Dominican Republic\" >Dominican Republic<\/option><option value=\"Ecuador\" >Ecuador<\/option><option value=\"Egypt\" >Egypt<\/option><option value=\"El Salvador\" >El Salvador<\/option><option value=\"Equatorial Guinea\" >Equatorial Guinea<\/option><option value=\"Eritrea\" >Eritrea<\/option><option value=\"Estonia\" >Estonia<\/option><option value=\"Eswatini (Kingdom of)\" >Eswatini (Kingdom of)<\/option><option value=\"Ethiopia\" >Ethiopia<\/option><option value=\"Falkland Islands (Malvinas)\" >Falkland Islands (Malvinas)<\/option><option value=\"Faroe Islands\" >Faroe Islands<\/option><option value=\"Fiji\" >Fiji<\/option><option value=\"Finland\" >Finland<\/option><option value=\"France\" >France<\/option><option value=\"French Guiana\" >French Guiana<\/option><option value=\"French Polynesia\" >French Polynesia<\/option><option value=\"French Southern Territories\" >French Southern Territories<\/option><option value=\"Gabon\" >Gabon<\/option><option value=\"Gambia\" >Gambia<\/option><option value=\"Georgia\" >Georgia<\/option><option value=\"Germany\" >Germany<\/option><option value=\"Ghana\" >Ghana<\/option><option value=\"Gibraltar\" >Gibraltar<\/option><option value=\"Greece\" >Greece<\/option><option value=\"Greenland\" >Greenland<\/option><option value=\"Grenada\" >Grenada<\/option><option value=\"Guadeloupe\" >Guadeloupe<\/option><option value=\"Guam\" >Guam<\/option><option value=\"Guatemala\" >Guatemala<\/option><option value=\"Guernsey\" >Guernsey<\/option><option value=\"Guinea\" >Guinea<\/option><option value=\"Guinea-Bissau\" >Guinea-Bissau<\/option><option value=\"Guyana\" >Guyana<\/option><option value=\"Haiti\" >Haiti<\/option><option value=\"Heard Island and McDonald Islands\" >Heard Island and McDonald Islands<\/option><option value=\"Honduras\" >Honduras<\/option><option value=\"Hong Kong\" >Hong Kong<\/option><option value=\"Hungary\" >Hungary<\/option><option value=\"Iceland\" >Iceland<\/option><option value=\"India\" >India<\/option><option value=\"Indonesia\" >Indonesia<\/option><option value=\"Iran (Islamic Republic of)\" >Iran (Islamic Republic of)<\/option><option value=\"Iraq\" >Iraq<\/option><option value=\"Ireland (Republic of)\" >Ireland (Republic of)<\/option><option value=\"Isle of Man\" >Isle of Man<\/option><option value=\"Israel\" >Israel<\/option><option value=\"Italy\" >Italy<\/option><option value=\"Jamaica\" >Jamaica<\/option><option value=\"Japan\" >Japan<\/option><option value=\"Jersey\" >Jersey<\/option><option value=\"Jordan\" >Jordan<\/option><option value=\"Kazakhstan\" >Kazakhstan<\/option><option value=\"Kenya\" >Kenya<\/option><option value=\"Kiribati\" >Kiribati<\/option><option value=\"Korea (Democratic People&#039;s Republic of)\" >Korea (Democratic People&#039;s Republic of)<\/option><option value=\"Korea (Republic of)\" >Korea (Republic of)<\/option><option value=\"Kosovo\" >Kosovo<\/option><option value=\"Kuwait\" >Kuwait<\/option><option value=\"Kyrgyzstan\" >Kyrgyzstan<\/option><option value=\"Lao People&#039;s Democratic Republic\" >Lao People&#039;s Democratic Republic<\/option><option value=\"Latvia\" >Latvia<\/option><option value=\"Lebanon\" >Lebanon<\/option><option value=\"Lesotho\" >Lesotho<\/option><option value=\"Liberia\" >Liberia<\/option><option value=\"Libya\" >Libya<\/option><option value=\"Liechtenstein\" >Liechtenstein<\/option><option value=\"Lithuania\" >Lithuania<\/option><option value=\"Luxembourg\" >Luxembourg<\/option><option value=\"Macao\" >Macao<\/option><option value=\"Madagascar\" >Madagascar<\/option><option value=\"Malawi\" >Malawi<\/option><option value=\"Malaysia\" >Malaysia<\/option><option value=\"Maldives\" >Maldives<\/option><option value=\"Mali\" >Mali<\/option><option value=\"Malta\" >Malta<\/option><option value=\"Marshall Islands\" >Marshall Islands<\/option><option value=\"Martinique\" >Martinique<\/option><option value=\"Mauritania\" >Mauritania<\/option><option value=\"Mauritius\" >Mauritius<\/option><option value=\"Mayotte\" >Mayotte<\/option><option value=\"Mexico\" >Mexico<\/option><option value=\"Micronesia (Federated States of)\" >Micronesia (Federated States of)<\/option><option value=\"Moldova (Republic of)\" >Moldova (Republic of)<\/option><option value=\"Monaco\" >Monaco<\/option><option value=\"Mongolia\" >Mongolia<\/option><option value=\"Montenegro\" >Montenegro<\/option><option value=\"Montserrat\" >Montserrat<\/option><option value=\"Morocco\" >Morocco<\/option><option value=\"Mozambique\" >Mozambique<\/option><option value=\"Myanmar\" >Myanmar<\/option><option value=\"Namibia\" >Namibia<\/option><option value=\"Nauru\" >Nauru<\/option><option value=\"Nepal\" >Nepal<\/option><option value=\"Netherlands\" >Netherlands<\/option><option value=\"New Caledonia\" >New Caledonia<\/option><option value=\"New Zealand\" >New Zealand<\/option><option value=\"Nicaragua\" >Nicaragua<\/option><option value=\"Niger\" >Niger<\/option><option value=\"Nigeria\" >Nigeria<\/option><option value=\"Niue\" >Niue<\/option><option value=\"Norfolk Island\" >Norfolk Island<\/option><option value=\"North Macedonia (Republic of)\" >North Macedonia (Republic of)<\/option><option value=\"Northern Mariana Islands\" >Northern Mariana Islands<\/option><option value=\"Norway\" >Norway<\/option><option value=\"Oman\" >Oman<\/option><option value=\"Pakistan\" >Pakistan<\/option><option value=\"Palau\" >Palau<\/option><option value=\"Palestine (State of)\" >Palestine (State of)<\/option><option value=\"Panama\" >Panama<\/option><option value=\"Papua New Guinea\" >Papua New Guinea<\/option><option value=\"Paraguay\" >Paraguay<\/option><option value=\"Peru\" >Peru<\/option><option value=\"Philippines\" >Philippines<\/option><option value=\"Pitcairn\" >Pitcairn<\/option><option value=\"Poland\" >Poland<\/option><option value=\"Portugal\" >Portugal<\/option><option value=\"Puerto Rico\" >Puerto Rico<\/option><option value=\"Qatar\" >Qatar<\/option><option value=\"Romania\" >Romania<\/option><option value=\"Russian Federation\" >Russian Federation<\/option><option value=\"Rwanda\" >Rwanda<\/option><option value=\"R\u00e9union\" >R\u00e9union<\/option><option value=\"Saint Barth\u00e9lemy\" >Saint Barth\u00e9lemy<\/option><option value=\"Saint Helena, Ascension and Tristan da Cunha\" >Saint Helena, Ascension and Tristan da Cunha<\/option><option value=\"Saint Kitts and Nevis\" >Saint Kitts and Nevis<\/option><option value=\"Saint Lucia\" >Saint Lucia<\/option><option value=\"Saint Martin (French part)\" >Saint Martin (French part)<\/option><option value=\"Saint Pierre and Miquelon\" >Saint Pierre and Miquelon<\/option><option value=\"Saint Vincent and the Grenadines\" >Saint Vincent and the Grenadines<\/option><option value=\"Samoa\" >Samoa<\/option><option value=\"San Marino\" >San Marino<\/option><option value=\"Sao Tome and Principe\" >Sao Tome and Principe<\/option><option value=\"Senegal\" >Senegal<\/option><option value=\"Serbia\" >Serbia<\/option><option value=\"Seychelles\" >Seychelles<\/option><option value=\"Sierra Leone\" >Sierra Leone<\/option><option value=\"Singapore\" >Singapore<\/option><option value=\"Sint Maarten (Dutch part)\" >Sint Maarten (Dutch part)<\/option><option value=\"Slovakia\" >Slovakia<\/option><option value=\"Slovenia\" >Slovenia<\/option><option value=\"Solomon Islands\" >Solomon Islands<\/option><option value=\"Somalia\" >Somalia<\/option><option value=\"South Africa\" >South Africa<\/option><option value=\"South Georgia and the South Sandwich Islands\" >South Georgia and the South Sandwich Islands<\/option><option value=\"South Sudan\" >South Sudan<\/option><option value=\"Spain\" >Spain<\/option><option value=\"Sri Lanka\" >Sri Lanka<\/option><option value=\"Sudan\" >Sudan<\/option><option value=\"Suriname\" >Suriname<\/option><option value=\"Svalbard and Jan Mayen\" >Svalbard and Jan Mayen<\/option><option value=\"Sweden\" >Sweden<\/option><option value=\"Switzerland\" >Switzerland<\/option><option value=\"Syrian Arab Republic\" >Syrian Arab Republic<\/option><option value=\"Taiwan, Republic of China\" >Taiwan, Republic of China<\/option><option value=\"Tajikistan\" >Tajikistan<\/option><option value=\"Tanzania (United Republic of)\" >Tanzania (United Republic of)<\/option><option value=\"Thailand\" >Thailand<\/option><option value=\"Timor-Leste\" >Timor-Leste<\/option><option value=\"Togo\" >Togo<\/option><option value=\"Tokelau\" >Tokelau<\/option><option value=\"Tonga\" >Tonga<\/option><option value=\"Trinidad and Tobago\" >Trinidad and Tobago<\/option><option value=\"Tunisia\" >Tunisia<\/option><option value=\"Turkmenistan\" >Turkmenistan<\/option><option value=\"Turks and Caicos Islands\" >Turks and Caicos Islands<\/option><option value=\"Tuvalu\" >Tuvalu<\/option><option value=\"T\u00fcrkiye\" >T\u00fcrkiye<\/option><option value=\"Uganda\" >Uganda<\/option><option value=\"Ukraine\" >Ukraine<\/option><option value=\"United Arab Emirates\" >United Arab Emirates<\/option><option value=\"United Kingdom of Great Britain and Northern Ireland\" >United Kingdom of Great Britain and Northern Ireland<\/option><option value=\"United States Minor Outlying Islands\" >United States Minor Outlying Islands<\/option><option value=\"United States of America\" >United States of America<\/option><option value=\"Uruguay\" >Uruguay<\/option><option value=\"Uzbekistan\" >Uzbekistan<\/option><option value=\"Vanuatu\" >Vanuatu<\/option><option value=\"Vatican City State\" >Vatican City State<\/option><option value=\"Venezuela (Bolivarian Republic of)\" >Venezuela (Bolivarian Republic of)<\/option><option value=\"Vietnam\" >Vietnam<\/option><option value=\"Virgin Islands (British)\" >Virgin Islands (British)<\/option><option value=\"Virgin Islands (U.S.)\" >Virgin Islands (U.S.)<\/option><option value=\"Wallis and Futuna\" >Wallis and Futuna<\/option><option value=\"Western Sahara\" >Western Sahara<\/option><option value=\"Yemen\" >Yemen<\/option><option value=\"Zambia\" >Zambia<\/option><option value=\"Zimbabwe\" >Zimbabwe<\/option><option value=\"\u00c5land Islands\" >\u00c5land Islands<\/option><\/select><\/div><div id=\"wpforms-2356-field_41-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"41\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_41\">   \u0627\u0644\u0639\u0645\u0631 | Age <\/label><input type=\"number\" id=\"wpforms-2356-field_41\" class=\"wpforms-field-small\" name=\"wpforms[fields][41]\" placeholder=\"Enter your age  \u0627\u062f\u062e\u0644 \u0627\u0644\u0639\u0645\u0631 \" step=\"any\" aria-errormessage=\"wpforms-2356-field_41-error\" ><\/div><div id=\"wpforms-2356-field_11-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"11\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_11\"> \u0627\u0644\u062c\u0646\u0633 | Gender  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2356-field_11\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][11]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled selected='selected'>Select | \u0627\u062e\u062a\u0631 <\/option><option value=\"Male\" >Male<\/option><option value=\"Female\" >Female<\/option><\/select><\/div><div id=\"wpforms-2356-field_42-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"42\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_42\"> \u0627\u0644\u0648\u0632\u0646 | Weight <\/label><input type=\"number\" id=\"wpforms-2356-field_42\" class=\"wpforms-field-small\" name=\"wpforms[fields][42]\" placeholder=\"Enter your weight  \u0625\u062f\u062e\u0627\u0644 \u0648\u0632\u0646\u0643\" step=\"any\" aria-errormessage=\"wpforms-2356-field_42-error\" ><\/div><div id=\"wpforms-2356-field_43-container\" class=\"wpforms-field wpforms-field-number\" data-field-id=\"43\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_43\"> \u0627\u0644\u0637\u0648\u0644 |  Height <\/label><input type=\"number\" id=\"wpforms-2356-field_43\" class=\"wpforms-field-small\" name=\"wpforms[fields][43]\" placeholder=\"Enter your height  \u0625\u062f\u062e\u0627\u0644 \u0627\u0644\u0637\u0648\u0644 \" step=\"any\" aria-errormessage=\"wpforms-2356-field_43-error\" ><\/div><div id=\"wpforms-2356-field_48-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"48\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_48\">\u0627\u0644\u062f\u0648\u0644\u0629 \u0627\u0644\u0645\u0637\u0644\u0648\u0628\u0629 \u0644\u0644\u0639\u0644\u0627\u062c  |  The country you require treatment in<\/label><input type=\"text\" id=\"wpforms-2356-field_48\" class=\"wpforms-field-medium\" name=\"wpforms[fields][48]\" placeholder=\"Enter the name of the required countries  |  \u0627\u062f\u062e\u0644 \u0627\u0633\u0645 \u0627\u0644\u062f\u0648\u0644 \u0627\u0644\u0645\u0637\u0644\u0648\u0628\u0629\" aria-errormessage=\"wpforms-2356-field_48-error\" ><\/div><div id=\"wpforms-2356-field_51-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"51\"><fieldset><legend class=\"wpforms-field-label\">\u0627\u0644\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0645\u062a\u0648\u0642\u0639 \u0644\u0644\u0639\u0644\u0627\u062c | Expected date of treatment <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-small\"><select name=\"wpforms[fields][51][date][d]\" id=\"wpforms-2356-field_51-day\" class=\"wpforms-field-date-time-date-day wpforms-field-required\" aria-label=\"Day\"  required><option value=\"\" class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][51][date][m]\" id=\"wpforms-2356-field_51-month\" class=\"wpforms-field-date-time-date-month wpforms-field-required\" aria-label=\"Month\"  required><option value=\"\" class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][51][date][y]\" id=\"wpforms-2356-field_51-year\" class=\"wpforms-field-date-time-date-year wpforms-field-required\" aria-label=\"Year\"  required><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" >1936<\/option><option value=\"1935\" >1935<\/option><option value=\"1934\" >1934<\/option><option value=\"1933\" >1933<\/option><option value=\"1932\" >1932<\/option><option value=\"1931\" >1931<\/option><option value=\"1930\" >1930<\/option><option value=\"1929\" >1929<\/option><option value=\"1928\" >1928<\/option><option value=\"1927\" >1927<\/option><option value=\"1926\" >1926<\/option><option value=\"1925\" >1925<\/option><option value=\"1924\" >1924<\/option><option value=\"1923\" >1923<\/option><option value=\"1922\" >1922<\/option><option value=\"1921\" >1921<\/option><option value=\"1920\" >1920<\/option><\/select><\/div><\/fieldset><\/div><div id=\"wpforms-2356-field_16-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"16\"><h3 id=\"wpforms-2356-field_16\" aria-errormessage=\"wpforms-2356-field_16-error\">\u0627\u0644\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0637\u0628\u064a | MEDICAL HISTORY <\/h3><\/div><div id=\"wpforms-2356-field_61-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-field-label-inline inputtypecheckbox inputtyperadio margin-left 5px margin-right wpforms-list-inline\" data-field-id=\"61\"><fieldset><legend class=\"wpforms-field-label\">\u0627\u0644\u0631\u0623\u0633 | HEAD  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2356-field_61\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_61_1\" name=\"wpforms[fields][61][]\" value=\"\u0635\u062f\u0627\u0639 \u0645\u0632\u0645\u0646   Headache Chronic\" aria-errormessage=\"wpforms-2356-field_61_1-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_61_1\">\u0635\u062f\u0627\u0639 \u0645\u0632\u0645\u0646   Headache Chronic<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_61_2\" name=\"wpforms[fields][61][]\" value=\"\u0635\u062f\u0627\u0639 \u0646\u0635\u0641\u064a   Migraine\" aria-errormessage=\"wpforms-2356-field_61_2-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_61_2\">\u0635\u062f\u0627\u0639 \u0646\u0635\u0641\u064a   Migraine<\/label><\/li><li class=\"choice-3 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_61_3\" name=\"wpforms[fields][61][]\" value=\"\u0635\u0631\u0639   Epilepsy\" aria-errormessage=\"wpforms-2356-field_61_3-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_61_3\">\u0635\u0631\u0639   Epilepsy<\/label><\/li><li class=\"choice-4 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_61_4\" name=\"wpforms[fields][61][]\" value=\"\u062a\u0634\u0646\u062c\u0627\u062a   Cramps\" aria-errormessage=\"wpforms-2356-field_61_4-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_61_4\">\u062a\u0634\u0646\u062c\u0627\u062a   Cramps<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_61_5\" name=\"wpforms[fields][61][]\" value=\"\u0644\u0627 \u064a\u0648\u062c\u062f   No\" aria-errormessage=\"wpforms-2356-field_61_5-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_61_5\">\u0644\u0627 \u064a\u0648\u062c\u062f   No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2356-field_66-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-field-label-inline inputtypecheckbox inputtyperadio margin-left 5px margin-right wpforms-list-inline\" data-field-id=\"66\"><fieldset><legend class=\"wpforms-field-label\"> \u0627\u0644\u0643\u0644\u0649  \/ KIDNEYS  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2356-field_66\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_66_1\" name=\"wpforms[fields][66][]\" value=\"\u0643\u0644\u0649 \u0627\u0644\u062a\u0647\u0627\u0628  Inflammation\" aria-errormessage=\"wpforms-2356-field_66_1-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_66_1\">\u0643\u0644\u0649 \u0627\u0644\u062a\u0647\u0627\u0628  Inflammation<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_66_2\" name=\"wpforms[fields][66][]\" value=\"\u062d\u0635\u0648\u0627\u062a \u0643\u0644\u0649  Kidney Stones\" aria-errormessage=\"wpforms-2356-field_66_2-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_66_2\">\u062d\u0635\u0648\u0627\u062a \u0643\u0644\u0649  Kidney Stones<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_66_5\" name=\"wpforms[fields][66][]\" value=\"\u0644\u0627 \u064a\u0648\u062c\u062f   No\" aria-errormessage=\"wpforms-2356-field_66_5-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_66_5\">\u0644\u0627 \u064a\u0648\u062c\u062f   No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2356-field_67-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-field-label-inline inputtypecheckbox inputtyperadio margin-left 5px margin-right wpforms-list-inline\" data-field-id=\"67\"><fieldset><legend class=\"wpforms-field-label\"> \u0627\u0644\u063a\u062f\u0629 \u0627\u0644\u062f\u0631\u0642\u064a\u0629 \/ THYROID GLAND  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2356-field_67\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_67_1\" name=\"wpforms[fields][67][]\" value=\"\u0627\u0644\u062a\u0647\u0627\u0628   Inflammation\" aria-errormessage=\"wpforms-2356-field_67_1-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_67_1\">\u0627\u0644\u062a\u0647\u0627\u0628   Inflammation<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_67_2\" name=\"wpforms[fields][67][]\" value=\"\u0642\u0635\u0648\u0631 \u0648\u0638\u064a\u0641\u064a   Hypofunction\" aria-errormessage=\"wpforms-2356-field_67_2-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_67_2\">\u0642\u0635\u0648\u0631 \u0648\u0638\u064a\u0641\u064a   Hypofunction<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_67_5\" name=\"wpforms[fields][67][]\" value=\"\u0644\u0627 \u064a\u0648\u062c\u062f   No\" aria-errormessage=\"wpforms-2356-field_67_5-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_67_5\">\u0644\u0627 \u064a\u0648\u062c\u062f   No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2356-field_68-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-field-label-inline inputtypecheckbox inputtyperadio margin-left 5px margin-right wpforms-list-inline\" data-field-id=\"68\"><fieldset><legend class=\"wpforms-field-label\">\u0627\u0644\u0639\u0645\u0648\u062f \u0627\u0644\u0641\u0642\u0631\u064a \/ SPINAL COLUMN <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2356-field_68\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_68_1\" name=\"wpforms[fields][68][]\" value=\"\u0627\u0646\u0632\u0644\u0627\u0642 \u063a\u0636\u0631\u0648\u0641\u064a   disc protrusion\" aria-errormessage=\"wpforms-2356-field_68_1-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_68_1\">\u0627\u0646\u0632\u0644\u0627\u0642 \u063a\u0636\u0631\u0648\u0641\u064a   disc protrusion<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_68_2\" name=\"wpforms[fields][68][]\" value=\"\u0636\u064a\u0651\u0642 \u0627\u0644\u0642\u0646\u0627\u0629 \u0627\u0644\u0634\u0648\u0643\u064a\u0629   Spinal Canal Stenosis\" aria-errormessage=\"wpforms-2356-field_68_2-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_68_2\">\u0636\u064a\u0651\u0642 \u0627\u0644\u0642\u0646\u0627\u0629 \u0627\u0644\u0634\u0648\u0643\u064a\u0629   Spinal Canal Stenosis<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_68_6\" name=\"wpforms[fields][68][]\" value=\"\u0625\u0635\u0627\u0628\u0629  injury\" aria-errormessage=\"wpforms-2356-field_68_6-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_68_6\">\u0625\u0635\u0627\u0628\u0629  injury<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_68_5\" name=\"wpforms[fields][68][]\" value=\"\u0644\u0627 \u064a\u0648\u062c\u062f   No\" aria-errormessage=\"wpforms-2356-field_68_5-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_68_5\">\u0644\u0627 \u064a\u0648\u062c\u062f   No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2356-field_69-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-field-label-inline inputtypecheckbox inputtyperadio margin-left 5px margin-right wpforms-list-inline\" data-field-id=\"69\"><fieldset><legend class=\"wpforms-field-label\">\u0627\u0644\u0623\u0645\u0631\u0627\u0636 \u0627\u0644\u0623\u064a\u0636\u064a\u0629 \/ METABOLIC DISEASES  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2356-field_69\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_69_1\" name=\"wpforms[fields][69][]\" value=\"\u0627\u0644\u0633\u0643\u0631\u064a   diabetes\" aria-errormessage=\"wpforms-2356-field_69_1-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_69_1\">\u0627\u0644\u0633\u0643\u0631\u064a   diabetes<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_69_2\" name=\"wpforms[fields][69][]\" value=\"\u0627\u0631\u062a\u0641\u0627\u0639 \u0627\u0644\u0643\u0648\u0644\u064a\u0633\u062a\u0631\u0648\u0644   high cholesterol\" aria-errormessage=\"wpforms-2356-field_69_2-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_69_2\">\u0627\u0631\u062a\u0641\u0627\u0639 \u0627\u0644\u0643\u0648\u0644\u064a\u0633\u062a\u0631\u0648\u0644   high cholesterol<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_69_5\" name=\"wpforms[fields][69][]\" value=\"\u0644\u0627 \u064a\u0648\u062c\u062f   No\" aria-errormessage=\"wpforms-2356-field_69_5-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_69_5\">\u0644\u0627 \u064a\u0648\u062c\u062f   No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2356-field_78-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-field-label-inline inputtypecheckbox inputtyperadio margin-left 5px margin-right wpforms-list-inline\" data-field-id=\"78\"><fieldset><legend class=\"wpforms-field-label\">\u0627\u0644\u0645\u0641\u0627\u0635\u0644 \u0648\u0627\u0644\u0639\u0638\u0627\u0645 \/ JOINTS and BONE <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2356-field_78\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_78_1\" name=\"wpforms[fields][78][]\" value=\"\u0627\u0644\u062a\u0647\u0627\u0628 \u0627\u0644\u0645\u0641\u0627\u0635\u0644   Arthrosis\" aria-errormessage=\"wpforms-2356-field_78_1-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_78_1\">\u0627\u0644\u062a\u0647\u0627\u0628 \u0627\u0644\u0645\u0641\u0627\u0635\u0644   Arthrosis<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_78_2\" name=\"wpforms[fields][78][]\" value=\"\u0627\u0644\u0631\u0648\u0645\u0627\u062a\u064a\u0632\u0645   Rheumatism\" aria-errormessage=\"wpforms-2356-field_78_2-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_78_2\">\u0627\u0644\u0631\u0648\u0645\u0627\u062a\u064a\u0632\u0645   Rheumatism<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_78_6\" name=\"wpforms[fields][78][]\" value=\"\u062c\u0631\u0627\u062d\u0629    Surgery\" aria-errormessage=\"wpforms-2356-field_78_6-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_78_6\">\u062c\u0631\u0627\u062d\u0629    Surgery<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_78_7\" name=\"wpforms[fields][78][]\" value=\"\u0643\u0633\u0631   Fracture\" aria-errormessage=\"wpforms-2356-field_78_7-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_78_7\">\u0643\u0633\u0631   Fracture<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_78_8\" name=\"wpforms[fields][78][]\" value=\"\u0627\u0635\u0627\u0628\u0627\u062a  Injuries\" aria-errormessage=\"wpforms-2356-field_78_8-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_78_8\">\u0627\u0635\u0627\u0628\u0627\u062a  Injuries<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_78_5\" name=\"wpforms[fields][78][]\" value=\"\u0644\u0627 \u064a\u0648\u062c\u062f   No\" aria-errormessage=\"wpforms-2356-field_78_5-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_78_5\">\u0644\u0627 \u064a\u0648\u062c\u062f   No<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2356-field_79-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-field-label-inline inputtypecheckbox inputtyperadio margin-left 5px margin-right wpforms-list-inline\" data-field-id=\"79\"><fieldset><legend class=\"wpforms-field-label\"> \u0627\u0644\u0642\u0644\u0628  \/ HEART     <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2356-field_79\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_79_1\" name=\"wpforms[fields][79][]\" value=\"\u0627\u0631\u062a\u0641\u0627\u0639 \u0636\u063a\u0637 \u0627\u0644\u062f\u0645    high blood pressure\" aria-errormessage=\"wpforms-2356-field_79_1-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_79_1\">\u0627\u0631\u062a\u0641\u0627\u0639 \u0636\u063a\u0637 \u0627\u0644\u062f\u0645    high blood pressure<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_79_2\" name=\"wpforms[fields][79][]\" value=\"\u0627\u0646\u062e\u0641\u0627\u0636 \u0636\u063a\u0637 \u0627\u0644\u062f\u0645     Down blood pressure\" aria-errormessage=\"wpforms-2356-field_79_2-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_79_2\">\u0627\u0646\u062e\u0641\u0627\u0636 \u0636\u063a\u0637 \u0627\u0644\u062f\u0645     Down blood pressure<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_79_6\" name=\"wpforms[fields][79][]\" value=\"\u062a\u062c\u0644\u0637 \u0627\u0644\u062f\u0645   Blood clotting\" aria-errormessage=\"wpforms-2356-field_79_6-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_79_6\">\u062a\u062c\u0644\u0637 \u0627\u0644\u062f\u0645   Blood clotting<\/label><\/li><li class=\"choice-7 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_79_7\" name=\"wpforms[fields][79][]\" value=\"\u0639\u062f\u0645 \u0627\u0646\u062a\u0638\u0627\u0645 \u0636\u0631\u0628\u0627\u062a \u0627\u0644\u0642\u0644\u0628   irregular heart Beats\" aria-errormessage=\"wpforms-2356-field_79_7-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_79_7\">\u0639\u062f\u0645 \u0627\u0646\u062a\u0638\u0627\u0645 \u0636\u0631\u0628\u0627\u062a \u0627\u0644\u0642\u0644\u0628   irregular heart Beats<\/label><\/li><li class=\"choice-8 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_79_8\" name=\"wpforms[fields][79][]\" value=\"\u062f\u0639\u0627\u0645\u0627\u062a  stents\" aria-errormessage=\"wpforms-2356-field_79_8-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_79_8\">\u062f\u0639\u0627\u0645\u0627\u062a  stents<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_79_5\" name=\"wpforms[fields][79][]\" value=\"\u0644\u0627 \u064a\u0648\u062c\u062f   N0\" aria-errormessage=\"wpforms-2356-field_79_5-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_79_5\">\u0644\u0627 \u064a\u0648\u062c\u062f   N0<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2356-field_92-container\" class=\"wpforms-field wpforms-field-checkbox wpforms-field-label-inline inputtypecheckbox inputtyperadio margin-left 5px margin-right wpforms-list-inline\" data-field-id=\"92\"><fieldset><legend class=\"wpforms-field-label\">\u0627\u0644\u0628\u0637\u0646 \/ ABDOMEN <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2356-field_92\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_92_1\" name=\"wpforms[fields][92][]\" value=\"\u0627\u0644\u062a\u0647\u0627\u0628 \u0627\u0644\u0643\u0628\u062f    hepatitis\" aria-errormessage=\"wpforms-2356-field_92_1-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_92_1\">\u0627\u0644\u062a\u0647\u0627\u0628 \u0627\u0644\u0643\u0628\u062f    hepatitis<\/label><\/li><li class=\"choice-2 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_92_2\" name=\"wpforms[fields][92][]\" value=\"\u062a\u0644\u064a\u0641 \u0627\u0644\u0643\u0628\u062f  Liver Cirrhosis\" aria-errormessage=\"wpforms-2356-field_92_2-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_92_2\">\u062a\u0644\u064a\u0641 \u0627\u0644\u0643\u0628\u062f  Liver Cirrhosis<\/label><\/li><li class=\"choice-6 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_92_6\" name=\"wpforms[fields][92][]\" value=\"Stomach Inflammation   \u0627\u0644\u062a\u0647\u0627\u0628 \u0627\u0644\u0645\u0639\u062f\u0629\" aria-errormessage=\"wpforms-2356-field_92_6-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_92_6\">Stomach Inflammation   \u0627\u0644\u062a\u0647\u0627\u0628 \u0627\u0644\u0645\u0639\u062f\u0629<\/label><\/li><li class=\"choice-5 depth-1\"><input type=\"checkbox\" id=\"wpforms-2356-field_92_5\" name=\"wpforms[fields][92][]\" value=\"\u0644\u0627 \u064a\u0648\u062c\u062f   N0\" aria-errormessage=\"wpforms-2356-field_92_5-error\" required><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_92_5\">\u0644\u0627 \u064a\u0648\u062c\u062f   N0<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2356-field_94-container\" class=\"wpforms-field wpforms-field-divider\" data-field-id=\"94\"><h3 id=\"wpforms-2356-field_94\" aria-errormessage=\"wpforms-2356-field_94-error\">\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0625\u0636\u0627\u0641\u064a\u0629 \/  Additional Information<\/h3><\/div><div id=\"wpforms-2356-field_19-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"19\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_19\"> \u0647\u0644 \u062a\u062a\u0646\u0627\u0648\u0644 \u0623\u064a \u062f\u0648\u0627\u0621 \u062d\u0627\u0644\u064a\u064b\u0627\u061f | Are you currently taking any medication? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2356-field_19\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][19]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled selected='selected'>Select | \u0627\u062e\u062a\u0631 <\/option><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-2356-field_20-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger\" data-field-id=\"20\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_20\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u0628\u0646\u0639\u0645\u060c \u064a\u0631\u062c\u0649 \u0643\u062a\u0627\u0628\u0629 \u0627\u0633\u0645 \u0627\u0644\u062f\u0648\u0627\u0621 | If yes, please write the name of the medication <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-2356-field_20\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][20]\" placeholder=\"Enter the names of the medications |  \u0627\u0643\u062a\u0628 \u0627\u0633\u0645 \u0627\u0644\u0623\u062f\u0648\u064a\u0629 \" aria-errormessage=\"wpforms-2356-field_20-error\" required><\/textarea><\/div><div id=\"wpforms-2356-field_21-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-field wpforms-conditional-show wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"21\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_21\"> \u0647\u0644 \u0633\u0628\u0642 \u0644\u0643 \u0623\u0646 \u062a\u0639\u0631\u0636\u062a \u0644\u0645\u0631\u0636 \u062e\u0637\u064a\u0631 \u0623\u0648 \u0625\u0635\u0627\u0628\u0629\u061f  | Have you ever suffered a serious illness or injury? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2356-field_21\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][21]\" required=\"required\"><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-2356-field_22-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"22\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_22\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u0646\u0639\u0645\u060c \u064a\u0631\u062c\u0649 \u062a\u0642\u062f\u064a\u0645 \u0627\u0644\u062a\u0641\u0627\u0635\u064a\u0644  |  If yes, please provide details <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-2356-field_22\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][22]\" aria-errormessage=\"wpforms-2356-field_22-error\" required><\/textarea><\/div><div id=\"wpforms-2356-field_27-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"27\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_27\">\u0647\u0644 \u0644\u062f\u064a\u0643 \u062d\u0633\u0627\u0633\u064a\u0629 \u062a\u062c\u0627\u0647 \u0623\u064a \u062f\u0648\u0627\u0621\u061f |  Are you allergic to any medication? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2356-field_27\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][27]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled selected='selected'>Select | \u0627\u062e\u062a\u0631 <\/option><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-2356-field_28-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"28\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_28\"> \u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u0646\u0639\u0645\u060c \u064a\u0631\u062c\u0649 \u062a\u0642\u062f\u064a\u0645 \u0627\u0644\u062a\u0641\u0627\u0635\u064a\u0644 | If yes, please provide details <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-2356-field_28\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][28]\" aria-errormessage=\"wpforms-2356-field_28-error\" required><\/textarea><\/div><div id=\"wpforms-2356-field_29-container\" class=\"wpforms-field wpforms-field-select wpforms-conditional-trigger wpforms-field-select-style-classic\" data-field-id=\"29\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_29\">\u0647\u0644 \u0647\u0646\u0627\u0643 \u0623\u064a \u0625\u0639\u0627\u0642\u0627\u062a \u0623\u0648 \u062d\u0627\u0644\u0627\u062a \u0623\u062e\u0631\u0649 \u063a\u064a\u0631 \u0627\u0644\u0645\u0630\u0643\u0648\u0631\u0629 \u0623\u0639\u0644\u0627\u0647\u061f |  Any other disabilities or conditions not mentioned above? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2356-field_29\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][29]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled selected='selected'>Select | \u0627\u062e\u062a\u0631 <\/option><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-2356-field_102-container\" class=\"wpforms-field wpforms-field-textarea wpforms-conditional-field wpforms-conditional-show\" data-field-id=\"102\" style=\"display:none;\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_102\">\u0625\u0630\u0627 \u0643\u0627\u0646\u062a \u0627\u0644\u0625\u062c\u0627\u0628\u0629 \u0628\u0646\u0639\u0645\u060c \u064a\u0631\u062c\u0649 \u062a\u0642\u062f\u064a\u0645 \u0627\u0644\u062a\u0641\u0627\u0635\u064a\u0644 |  If yes, please provide details <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><textarea id=\"wpforms-2356-field_102\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][102]\" aria-errormessage=\"wpforms-2356-field_102-error\" required><\/textarea><\/div><div id=\"wpforms-2356-field_93-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"93\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_93\">\u0647\u0644 \u0627\u0644\u0645\u0631\u064a\u0636 \u0642\u0627\u062f\u0631 \u0639\u0644\u0649 \u0627\u0631\u062a\u062f\u0627\u0621 \u0627\u0644\u0645\u0644\u0627\u0628\u0633 \u0628\u0646\u0641\u0633\u0647  \/ Is the patient able to dress themselves?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2356-field_93\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][93]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled selected='selected'>Select | \u0627\u062e\u062a\u0631 <\/option><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-2356-field_95-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"95\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_95\"> \u0647\u0644 \u0627\u0644\u0645\u0631\u064a\u0636 \u0642\u0627\u062f\u0631 \u0639\u0644\u0649 \u0627\u0644\u062a\u062d\u0631\u0643 \u0628\u062f\u0648\u0646 \u0645\u0633\u0627\u0639\u062f\u0629 \u0634\u062e\u0635 \u0622\u062e\u0631\u061f \/ Is the patient able to move without the assistance of another person? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2356-field_95\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][95]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled selected='selected'>Select | \u0627\u062e\u062a\u0631 <\/option><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-2356-field_96-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"96\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_96\">\u0647\u0644 \u0627\u0644\u0645\u0631\u064a\u0636 \u064a\u062d\u062a\u0627\u062c \u0627\u0644\u064a \u0645\u0631\u0627\u0641\u0642\u061f  \/ Does the patient need a companion?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2356-field_96\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][96]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled selected='selected'>Select | \u0627\u062e\u062a\u0631 <\/option><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-2356-field_97-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"97\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_97\"> \u0647\u0644 \u064a\u0633\u062a\u062e\u062f\u0645 \u0627\u0644\u0645\u0631\u064a\u0636 \u0643\u0631\u0633\u064a\u064b\u0627 \u0645\u062a\u062d\u0631\u0643\u064b\u0627\u061f  \/ Does the patient use a wheelchair?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2356-field_97\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][97]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled selected='selected'>Select | \u0627\u062e\u062a\u0631 <\/option><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-2356-field_99-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"99\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_99\">\u0647\u0644 \u0627\u0644\u0645\u0631\u064a\u0636 \u064a\u0633\u062a\u062e\u062f\u0645 \u0627\u0644\u0639\u0643\u0627\u0632\u0627\u062a\u061f  \/ Does the patient use crutches?  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2356-field_99\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][99]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled selected='selected'>Select | \u0627\u062e\u062a\u0631 <\/option><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-2356-field_98-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"98\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_98\">\u0647\u0644 \u0627\u0644\u0645\u0631\u064a\u0636 \u064a\u062a\u062d\u062f\u062b \u0627\u0644\u0644\u063a\u0629 \u0627\u0644\u0639\u0631\u0628\u064a\u0629\u061f  \/ Does the patient understand Arabic? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2356-field_98\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][98]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled selected='selected'>Select | \u0627\u062e\u062a\u0631 <\/option><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-2356-field_100-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"100\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_100\">\u0647\u0644 \u0627\u0644\u0645\u0631\u064a\u0636 \u064a\u062a\u062d\u062f\u062b \u0627\u0644\u0644\u063a\u0629 \u0627\u0644\u0625\u0646\u062c\u0644\u064a\u0632\u064a\u0629\u061f  \/ Does the patient understand English? <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2356-field_100\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][100]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled selected='selected'>Select | \u0627\u062e\u062a\u0631 <\/option><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-2356-field_101-container\" class=\"wpforms-field wpforms-field-select wpforms-field-select-style-classic\" data-field-id=\"101\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_101\">\u0647\u0644 \u0627\u0644\u0645\u0631\u064a\u0636 \u0627\u0644\u0639\u0645\u064a\u0644 \u064a\u062d\u062a\u0627\u062c \u0625\u0644\u0649 \u0646\u0648\u0639 \u062e\u0627\u0635 \u0645\u0646 \u0627\u0644\u0646\u0642\u0644 \u0645\u0646\/\u0625\u0644\u0649 \u0627\u0644\u0645\u0637\u0627\u0631 (\u0627\u062e\u0644\u0627\u0621 \u0637\u0628\u064a ) \/ &quot;Does the patient\/client need a special type of transportation from\/to the airport (medical evacuation)?&quot; <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><select id=\"wpforms-2356-field_101\" class=\"wpforms-field-small wpforms-field-required\" name=\"wpforms[fields][101]\" required=\"required\"><option value=\"\" class=\"placeholder\" disabled selected='selected'>Select | \u0627\u062e\u062a\u0631 <\/option><option value=\"No\" >No<\/option><option value=\"Yes\" >Yes<\/option><\/select><\/div><div id=\"wpforms-2356-field_104-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"104\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_104\">\u0627\u0644\u0627\u062c\u0631\u0627\u0621 \u0627\u0644\u0637\u0628\u064a \u0627\u0644\u0645\u0637\u0644\u0648\u0628  \/   Medical Procedure Required  <\/label><input type=\"text\" id=\"wpforms-2356-field_104\" class=\"wpforms-field-large\" name=\"wpforms[fields][104]\" placeholder=\" Enter the required procedure | \u0627\u0643\u062a\u0628 \u0647\u0646\u0627 \u0627\u0644\u0625\u062c\u0631\u0627\u0621 \u0627\u0644\u0645\u0637\u0644\u0648\u0628 \" aria-errormessage=\"wpforms-2356-field_104-error\" ><\/div><div id=\"wpforms-2356-field_9-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"9\"><fieldset><legend class=\"wpforms-field-label\">\u0625\u0642\u0631\u0627\u0631 \u0648\u0627\u0644\u062a\u0632\u0627\u0645 \u0628\u0627\u0644\u0645\u0648\u0627\u0641\u0642\u0629\t| Consent and Acknowledgment: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2356-field_9\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"checkbox\" id=\"wpforms-2356-field_9_1\" name=\"wpforms[fields][9][]\" value=\"\u0623\u0648\u0627\u0641\u0642 \u0648\u0627\u0642\u0631 \u0639\u0644\u0649 \u0635\u062d\u0629 \u062c\u0645\u064a\u0639 \u0627\u0644\u0628\u064a\u0627\u0646\u0627\u062a \u0648\u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u0635\u062d\u064a\u0629 \u0648 \u0627\u0644\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0645\u0631\u0636\u064a \u0648\u0627\u0644\u0623\u062f\u0648\u064a\u0629 \u0648\u0623\u062f\u0631\u0643 \u0623\u0646 \u0647\u0630\u0647 \u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0633\u062a\u0633\u062a\u062e\u062f\u0645 \u0641\u0642\u0637 \u0644\u0623\u063a\u0631\u0627\u0636 \u062a\u0642\u062f\u064a\u0645 \u0627\u0644\u0631\u0639\u0627\u064a\u0629 \u0627\u0644\u0635\u062d\u064a\u0629 \u0648\u0641\u064a \u062d\u0627\u0644 \u0639\u062f\u0645 \u062f\u0642\u062a\u0647\u0627 \u0627\u0648 \u0639\u062f\u0645 \u0627\u0644\u0625\u0641\u0635\u0627\u062d \u0639\u0646 \u0623\u064a \u0628\u064a\u0627\u0646\u0627\u062a \u0637\u0628\u064a\u0629 \u062a\u0639\u062a\u0628\u0631 \u062a\u062d\u062a \u0645\u0633\u0624\u0648\u0644\u064a\u062a\u064a \u0627\u0644\u0634\u062e\u0635\u064a\u0629 \u0648\u0627\u0644\u0645\u0627\u0644\u064a\u0629 \u0641\u064a \u062d\u0627\u0644 \u0648\u0642\u0648\u0639 \u0623\u064a \u0645\u0636\u0627\u0639\u0641\u0627\u062a \u0637\u0628\u064a\u0629 \u0644\u0623\u0642\u062f\u0631 \u0627\u0644\u0644\u0647. I agree and acknowledge the accuracy of all health data, medical history, and medications, and I understand that this information will be used solely for the purpose of providing healthcare. In case of any inaccuracies or failure to disclose any medical information, I accept full personal and financial responsibility in the event of any medical complications, God forbid. \u0623\u0642\u0631 \u0628\u0623\u0646\u0646\u064a \u0642\u062f \u062a\u0645 \u0625\u0639\u0644\u0627\u0645\u064a \u0628\u062d\u0642\u0648\u0642\u064a \u0643\u0645\u0631\u064a\u0636 \u0648\u0641\u0642\u0627\u064b \u0644\u0645\u062a\u0637\u0644\u0628\u0627\u062a \u0627\u0644\u0627\u0639\u062a\u0645\u0627\u062f \u0627\u0644\u0639\u0627\u0644\u0645\u064a \u0644\u0644\u0631\u0639\u0627\u064a\u0629 \u0627\u0644\u0635\u062d\u064a\u0629 (GHA). I acknowledge that I have been informed of my patient rights according to GHA requirements.  \u0623\u0648\u0627\u0641\u0642 \u0639\u0644\u0649 \u0633\u064a\u0627\u0633\u0629 \u0627\u0644\u062e\u0635\u0648\u0635\u064a\u0629 \u0648\u062d\u0645\u0627\u064a\u0629 \u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u0635\u062d\u064a\u0629 \u0627\u0644\u062e\u0627\u0635\u0629 \u0628\u064a \u0648\u0641\u0642 \u0642\u0627\u0646\u0648\u0646 (HIPAA). I agree to the privacy policy and the protection of my health information in accordance with HIPAA regulations.  Security and Privacy Notice  \u062a\u0646\u0648\u064a\u0647 \u0627\u0644\u0623\u0645\u0627\u0646 \u0648\u0627\u0644\u062e\u0635\u0648\u0635\u064a\u0629  \u064a\u062a\u0645 \u062d\u0641\u0638 \u0648\u062d\u0645\u0627\u064a\u0629 \u062c\u0645\u064a\u0639 \u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u0634\u062e\u0635\u064a\u0629 \u0648\u0627\u0644\u0637\u0628\u064a\u0629 \u0644\u0644\u0645\u0631\u064a\u0636 \u0648\u0641\u0642\u064b\u0627 \u0644\u0645\u062a\u0637\u0644\u0628\u0627\u062a \u0642\u0627\u0646\u0648\u0646 \u062d\u0645\u0627\u064a\u0629 \u062e\u0635\u0648\u0635\u064a\u0629 \u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u0635\u062d\u064a\u0629 (HIPAA). All personal and medical information of the patient is stored and protected in accordance with the requirements of the Health Insurance Portability and Accountability Act (HIPAA). \u064a\u062a\u0645 \u0627\u0633\u062a\u062e\u062f\u0627\u0645 \u0647\u0630\u0647 \u0627\u0644\u0628\u064a\u0627\u0646\u0627\u062a \u0641\u0642\u0637 \u0644\u0623\u063a\u0631\u0627\u0636 \u062a\u0642\u062f\u064a\u0645 \u0627\u0644\u0631\u0639\u0627\u064a\u0629 \u0627\u0644\u0637\u0628\u064a\u0629 \u0648\u064a\u062a\u0645 \u0627\u0644\u062a\u0639\u0627\u0645\u0644 \u0645\u0639\u0647\u0627 \u0628\u0633\u0631\u064a\u0629 \u062a\u0627\u0645\u0629 (HIPAA) This data is used only for the purpose of providing medical care and is handled with strict confidentiality.\" aria-errormessage=\"wpforms-2356-field_9_1-error\" required checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_9_1\">\u0623\u0648\u0627\u0641\u0642 \u0648\u0627\u0642\u0631 \u0639\u0644\u0649 \u0635\u062d\u0629 \u062c\u0645\u064a\u0639 \u0627\u0644\u0628\u064a\u0627\u0646\u0627\u062a \u0648\u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u0635\u062d\u064a\u0629 \u0648 \u0627\u0644\u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0645\u0631\u0636\u064a \u0648\u0627\u0644\u0623\u062f\u0648\u064a\u0629 \u0648\u0623\u062f\u0631\u0643 \u0623\u0646 \u0647\u0630\u0647 \u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0633\u062a\u0633\u062a\u062e\u062f\u0645 \u0641\u0642\u0637 \u0644\u0623\u063a\u0631\u0627\u0636 \u062a\u0642\u062f\u064a\u0645 \u0627\u0644\u0631\u0639\u0627\u064a\u0629 \u0627\u0644\u0635\u062d\u064a\u0629 \u0648\u0641\u064a \u062d\u0627\u0644 \u0639\u062f\u0645 \u062f\u0642\u062a\u0647\u0627 \u0627\u0648 \u0639\u062f\u0645 \u0627\u0644\u0625\u0641\u0635\u0627\u062d \u0639\u0646 \u0623\u064a \u0628\u064a\u0627\u0646\u0627\u062a \u0637\u0628\u064a\u0629 \u062a\u0639\u062a\u0628\u0631 \u062a\u062d\u062a \u0645\u0633\u0624\u0648\u0644\u064a\u062a\u064a \u0627\u0644\u0634\u062e\u0635\u064a\u0629 \u0648\u0627\u0644\u0645\u0627\u0644\u064a\u0629 \u0641\u064a \u062d\u0627\u0644 \u0648\u0642\u0648\u0639 \u0623\u064a \u0645\u0636\u0627\u0639\u0641\u0627\u062a \u0637\u0628\u064a\u0629 \u0644\u0623\u0642\u062f\u0631 \u0627\u0644\u0644\u0647. I agree and acknowledge the accuracy of all health data, medical history, and medications, and I understand that this information will be used solely for the purpose of providing healthcare. In case of any inaccuracies or failure to disclose any medical information, I accept full personal and financial responsibility in the event of any medical complications, God forbid. \u0623\u0642\u0631 \u0628\u0623\u0646\u0646\u064a \u0642\u062f \u062a\u0645 \u0625\u0639\u0644\u0627\u0645\u064a \u0628\u062d\u0642\u0648\u0642\u064a \u0643\u0645\u0631\u064a\u0636 \u0648\u0641\u0642\u0627\u064b \u0644\u0645\u062a\u0637\u0644\u0628\u0627\u062a \u0627\u0644\u0627\u0639\u062a\u0645\u0627\u062f \u0627\u0644\u0639\u0627\u0644\u0645\u064a \u0644\u0644\u0631\u0639\u0627\u064a\u0629 \u0627\u0644\u0635\u062d\u064a\u0629 (GHA). I acknowledge that I have been informed of my patient rights according to GHA requirements.  \u0623\u0648\u0627\u0641\u0642 \u0639\u0644\u0649 \u0633\u064a\u0627\u0633\u0629 \u0627\u0644\u062e\u0635\u0648\u0635\u064a\u0629 \u0648\u062d\u0645\u0627\u064a\u0629 \u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u0635\u062d\u064a\u0629 \u0627\u0644\u062e\u0627\u0635\u0629 \u0628\u064a \u0648\u0641\u0642 \u0642\u0627\u0646\u0648\u0646 (HIPAA). I agree to the privacy policy and the protection of my health information in accordance with HIPAA regulations.  Security and Privacy Notice  \u062a\u0646\u0648\u064a\u0647 \u0627\u0644\u0623\u0645\u0627\u0646 \u0648\u0627\u0644\u062e\u0635\u0648\u0635\u064a\u0629  \u064a\u062a\u0645 \u062d\u0641\u0638 \u0648\u062d\u0645\u0627\u064a\u0629 \u062c\u0645\u064a\u0639 \u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u0634\u062e\u0635\u064a\u0629 \u0648\u0627\u0644\u0637\u0628\u064a\u0629 \u0644\u0644\u0645\u0631\u064a\u0636 \u0648\u0641\u0642\u064b\u0627 \u0644\u0645\u062a\u0637\u0644\u0628\u0627\u062a \u0642\u0627\u0646\u0648\u0646 \u062d\u0645\u0627\u064a\u0629 \u062e\u0635\u0648\u0635\u064a\u0629 \u0627\u0644\u0645\u0639\u0644\u0648\u0645\u0627\u062a \u0627\u0644\u0635\u062d\u064a\u0629 (HIPAA). All personal and medical information of the patient is stored and protected in accordance with the requirements of the Health Insurance Portability and Accountability Act (HIPAA). \u064a\u062a\u0645 \u0627\u0633\u062a\u062e\u062f\u0627\u0645 \u0647\u0630\u0647 \u0627\u0644\u0628\u064a\u0627\u0646\u0627\u062a \u0641\u0642\u0637 \u0644\u0623\u063a\u0631\u0627\u0636 \u062a\u0642\u062f\u064a\u0645 \u0627\u0644\u0631\u0639\u0627\u064a\u0629 \u0627\u0644\u0637\u0628\u064a\u0629 \u0648\u064a\u062a\u0645 \u0627\u0644\u062a\u0639\u0627\u0645\u0644 \u0645\u0639\u0647\u0627 \u0628\u0633\u0631\u064a\u0629 \u062a\u0627\u0645\u0629 (HIPAA) This data is used only for the purpose of providing medical care and is handled with strict confidentiality.<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2356-field_38-container\" class=\"wpforms-field wpforms-field-checkbox\" data-field-id=\"38\"><fieldset><legend class=\"wpforms-field-label\">\u062a\u0641\u0648\u064a\u0636 \u0631\u0633\u0645\u064a \u0648\u0625\u0642\u0631\u0627\u0631 \u0628\u0627\u0644\u0645\u0648\u0627\u0641\u0642\u0629:\tPower of attorney and declaration of consent: <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><ul id=\"wpforms-2356-field_38\" class=\"wpforms-field-required\"><li class=\"choice-1 depth-1 wpforms-selected\"><input type=\"checkbox\" id=\"wpforms-2356-field_38_1\" name=\"wpforms[fields][38][]\" value=\"&quot;\u0623\u0642\u0631\u0651 \u0623\u0646\u0627 \u0627\u0644\u0645\u0648\u0642\u0639 \u0623\u062f\u0646\u0627\u0647 \u0628\u0623\u0646\u0646\u064a \u0623\u0645\u0646\u062d \u0634\u0631\u0643\u0629 \u0627\u0644\u062a\u0646\u0633\u064a\u0642 \u0648\u0627\u0644\u062a\u0646\u0638\u064a\u0645 \u0644\u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0633\u064a\u0627\u062d\u0629 \u0627\u0644\u0639\u0644\u0627\u062c\u064a\u0629 \u0648\u0641\u0631\u064a\u0642\u0647\u0627 \u0627\u0644\u0637\u0628\u064a \u0627\u0644\u062d\u0642 \u0641\u064a \u0627\u0644\u0648\u0635\u0648\u0644 \u0625\u0644\u0649 \u062c\u0645\u064a\u0639 \u0645\u0639\u0644\u0648\u0645\u0627\u062a\u064a \u0627\u0644\u0634\u062e\u0635\u064a\u0629 \u0648\u062d\u0627\u0644\u062a\u064a \u0627\u0644\u0635\u062d\u064a\u0629\u060c \u0628\u0645\u0627 \u0641\u064a \u0630\u0644\u0643 \u0627\u0644\u0627\u0637\u0644\u0627\u0639 \u0627\u0644\u0643\u0627\u0645\u0644 \u0639\u0644\u0649 \u0633\u062c\u0644\u0627\u062a\u064a \u0627\u0644\u0637\u0628\u064a\u0629. \u0643\u0645\u0627 \u0623\u0633\u0645\u062d \u0644\u0647\u0645 \u0628\u062c\u0645\u0639 \u0627\u0644\u0628\u064a\u0627\u0646\u0627\u062a \u0630\u0627\u062a \u0627\u0644\u0635\u0644\u0629 \u0648\u0645\u0634\u0627\u0631\u0643\u062a\u0647\u0627 \u0645\u0639 \u0645\u0642\u062f\u0645\u064a \u0627\u0644\u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0637\u0628\u064a\u0629 \u0648\u0627\u0644\u0623\u0637\u0628\u0627\u0621 \u062f\u0627\u062e\u0644 \u0627\u0644\u0645\u0645\u0644\u0643\u0629 \u0648\u062e\u0627\u0631\u062c\u0647\u0627\u060c \u0644\u063a\u0631\u0636 \u062a\u0642\u062f\u064a\u0645 \u0627\u0644\u0631\u0639\u0627\u064a\u0629 \u0627\u0644\u0637\u0628\u064a\u0629 \u0627\u0644\u0644\u0627\u0632\u0645\u0629 \u0648\u0627\u0644\u0645\u0648\u0635\u064a \u0628\u0647\u0627.&quot; &quot;I, the undersigned, hereby acknowledge and declare that I grant the Coordination and Organization Company for Medical Tourism Services and its medical team the right to access all my personal information and health status, including full access to my medical records. I also allow them to collect and share relevant data with medical service providers and physicians inside and outside the Kingdom, for the purpose of providing the necessary and recommended medical care.&quot;\" aria-errormessage=\"wpforms-2356-field_38_1-error\" required checked='checked'><label class=\"wpforms-field-label-inline\" for=\"wpforms-2356-field_38_1\">\"\u0623\u0642\u0631\u0651 \u0623\u0646\u0627 \u0627\u0644\u0645\u0648\u0642\u0639 \u0623\u062f\u0646\u0627\u0647 \u0628\u0623\u0646\u0646\u064a \u0623\u0645\u0646\u062d \u0634\u0631\u0643\u0629 \u0627\u0644\u062a\u0646\u0633\u064a\u0642 \u0648\u0627\u0644\u062a\u0646\u0638\u064a\u0645 \u0644\u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0633\u064a\u0627\u062d\u0629 \u0627\u0644\u0639\u0644\u0627\u062c\u064a\u0629 \u0648\u0641\u0631\u064a\u0642\u0647\u0627 \u0627\u0644\u0637\u0628\u064a \u0627\u0644\u062d\u0642 \u0641\u064a \u0627\u0644\u0648\u0635\u0648\u0644 \u0625\u0644\u0649 \u062c\u0645\u064a\u0639 \u0645\u0639\u0644\u0648\u0645\u0627\u062a\u064a \u0627\u0644\u0634\u062e\u0635\u064a\u0629 \u0648\u062d\u0627\u0644\u062a\u064a \u0627\u0644\u0635\u062d\u064a\u0629\u060c \u0628\u0645\u0627 \u0641\u064a \u0630\u0644\u0643 \u0627\u0644\u0627\u0637\u0644\u0627\u0639 \u0627\u0644\u0643\u0627\u0645\u0644 \u0639\u0644\u0649 \u0633\u062c\u0644\u0627\u062a\u064a \u0627\u0644\u0637\u0628\u064a\u0629. \u0643\u0645\u0627 \u0623\u0633\u0645\u062d \u0644\u0647\u0645 \u0628\u062c\u0645\u0639 \u0627\u0644\u0628\u064a\u0627\u0646\u0627\u062a \u0630\u0627\u062a \u0627\u0644\u0635\u0644\u0629 \u0648\u0645\u0634\u0627\u0631\u0643\u062a\u0647\u0627 \u0645\u0639 \u0645\u0642\u062f\u0645\u064a \u0627\u0644\u062e\u062f\u0645\u0627\u062a \u0627\u0644\u0637\u0628\u064a\u0629 \u0648\u0627\u0644\u0623\u0637\u0628\u0627\u0621 \u062f\u0627\u062e\u0644 \u0627\u0644\u0645\u0645\u0644\u0643\u0629 \u0648\u062e\u0627\u0631\u062c\u0647\u0627\u060c \u0644\u063a\u0631\u0636 \u062a\u0642\u062f\u064a\u0645 \u0627\u0644\u0631\u0639\u0627\u064a\u0629 \u0627\u0644\u0637\u0628\u064a\u0629 \u0627\u0644\u0644\u0627\u0632\u0645\u0629 \u0648\u0627\u0644\u0645\u0648\u0635\u064a \u0628\u0647\u0627.\" \"I, the undersigned, hereby acknowledge and declare that I grant the Coordination and Organization Company for Medical Tourism Services and its medical team the right to access all my personal information and health status, including full access to my medical records. I also allow them to collect and share relevant data with medical service providers and physicians inside and outside the Kingdom, for the purpose of providing the necessary and recommended medical care.\"<\/label><\/li><\/ul><\/fieldset><\/div><div id=\"wpforms-2356-field_47-container\" class=\"wpforms-field wpforms-field-text\" data-field-id=\"47\"><label class=\"wpforms-field-label\" for=\"wpforms-2356-field_47\"> \u062a\u0648\u0642\u064a\u0639 \u0627\u0644\u0645\u0631\u064a\u0636 | Patient&#039;s Signature  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/label><input type=\"text\" id=\"wpforms-2356-field_47\" class=\"wpforms-field-medium wpforms-field-required\" name=\"wpforms[fields][47]\" placeholder=\" \u0627\u0644\u0627\u0633\u0645 \u0643\u0627\u0645\u0644\u0627  | Full Name\" aria-errormessage=\"wpforms-2356-field_47-error\" required><\/div><div id=\"wpforms-2356-field_32-container\" class=\"wpforms-field wpforms-field-date-time\" data-field-id=\"32\"><fieldset><legend class=\"wpforms-field-label\"> \u0627\u0644\u062a\u0627\u0631\u064a\u062e | Date  <span class=\"wpforms-required-label\" aria-hidden=\"true\">*<\/span><\/legend><div class=\"wpforms-field-date-dropdown-wrap wpforms-field-small\"><select name=\"wpforms[fields][32][date][d]\" id=\"wpforms-2356-field_32-day\" class=\"wpforms-field-date-time-date-day wpforms-field-required\" aria-label=\"Day\"  required><option value=\"\" class=\"placeholder\" selected disabled>DD<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><option value=\"13\" >13<\/option><option value=\"14\" >14<\/option><option value=\"15\" >15<\/option><option value=\"16\" >16<\/option><option value=\"17\" >17<\/option><option value=\"18\" >18<\/option><option value=\"19\" >19<\/option><option value=\"20\" >20<\/option><option value=\"21\" >21<\/option><option value=\"22\" >22<\/option><option value=\"23\" >23<\/option><option value=\"24\" >24<\/option><option value=\"25\" >25<\/option><option value=\"26\" >26<\/option><option value=\"27\" >27<\/option><option value=\"28\" >28<\/option><option value=\"29\" >29<\/option><option value=\"30\" >30<\/option><option value=\"31\" >31<\/option><\/select><select name=\"wpforms[fields][32][date][m]\" id=\"wpforms-2356-field_32-month\" class=\"wpforms-field-date-time-date-month wpforms-field-required\" aria-label=\"Month\"  required><option value=\"\" class=\"placeholder\" selected disabled>MM<\/option><option value=\"1\" >1<\/option><option value=\"2\" >2<\/option><option value=\"3\" >3<\/option><option value=\"4\" >4<\/option><option value=\"5\" >5<\/option><option value=\"6\" >6<\/option><option value=\"7\" >7<\/option><option value=\"8\" >8<\/option><option value=\"9\" >9<\/option><option value=\"10\" >10<\/option><option value=\"11\" >11<\/option><option value=\"12\" >12<\/option><\/select><select name=\"wpforms[fields][32][date][y]\" id=\"wpforms-2356-field_32-year\" class=\"wpforms-field-date-time-date-year wpforms-field-required\" aria-label=\"Year\"  required><option value=\"\" class=\"placeholder\" selected disabled>YYYY<\/option><option value=\"2027\" >2027<\/option><option value=\"2026\" >2026<\/option><option value=\"2025\" >2025<\/option><option value=\"2024\" >2024<\/option><option value=\"2023\" >2023<\/option><option value=\"2022\" >2022<\/option><option value=\"2021\" >2021<\/option><option value=\"2020\" >2020<\/option><option value=\"2019\" >2019<\/option><option value=\"2018\" >2018<\/option><option value=\"2017\" >2017<\/option><option value=\"2016\" >2016<\/option><option value=\"2015\" >2015<\/option><option value=\"2014\" >2014<\/option><option value=\"2013\" >2013<\/option><option value=\"2012\" >2012<\/option><option value=\"2011\" >2011<\/option><option value=\"2010\" >2010<\/option><option value=\"2009\" >2009<\/option><option value=\"2008\" >2008<\/option><option value=\"2007\" >2007<\/option><option value=\"2006\" >2006<\/option><option value=\"2005\" >2005<\/option><option value=\"2004\" >2004<\/option><option value=\"2003\" >2003<\/option><option value=\"2002\" >2002<\/option><option value=\"2001\" >2001<\/option><option value=\"2000\" >2000<\/option><option value=\"1999\" >1999<\/option><option value=\"1998\" >1998<\/option><option value=\"1997\" >1997<\/option><option value=\"1996\" >1996<\/option><option value=\"1995\" >1995<\/option><option value=\"1994\" >1994<\/option><option value=\"1993\" >1993<\/option><option value=\"1992\" >1992<\/option><option value=\"1991\" >1991<\/option><option value=\"1990\" >1990<\/option><option value=\"1989\" >1989<\/option><option value=\"1988\" >1988<\/option><option value=\"1987\" >1987<\/option><option value=\"1986\" >1986<\/option><option value=\"1985\" >1985<\/option><option value=\"1984\" >1984<\/option><option value=\"1983\" >1983<\/option><option value=\"1982\" >1982<\/option><option value=\"1981\" >1981<\/option><option value=\"1980\" >1980<\/option><option value=\"1979\" >1979<\/option><option value=\"1978\" >1978<\/option><option value=\"1977\" >1977<\/option><option value=\"1976\" >1976<\/option><option value=\"1975\" >1975<\/option><option value=\"1974\" >1974<\/option><option value=\"1973\" >1973<\/option><option value=\"1972\" >1972<\/option><option value=\"1971\" >1971<\/option><option value=\"1970\" >1970<\/option><option value=\"1969\" >1969<\/option><option value=\"1968\" >1968<\/option><option value=\"1967\" >1967<\/option><option value=\"1966\" >1966<\/option><option value=\"1965\" >1965<\/option><option value=\"1964\" >1964<\/option><option value=\"1963\" >1963<\/option><option value=\"1962\" >1962<\/option><option value=\"1961\" >1961<\/option><option value=\"1960\" >1960<\/option><option value=\"1959\" >1959<\/option><option value=\"1958\" >1958<\/option><option value=\"1957\" >1957<\/option><option value=\"1956\" >1956<\/option><option value=\"1955\" >1955<\/option><option value=\"1954\" >1954<\/option><option value=\"1953\" >1953<\/option><option value=\"1952\" >1952<\/option><option value=\"1951\" >1951<\/option><option value=\"1950\" >1950<\/option><option value=\"1949\" >1949<\/option><option value=\"1948\" >1948<\/option><option value=\"1947\" >1947<\/option><option value=\"1946\" >1946<\/option><option value=\"1945\" >1945<\/option><option value=\"1944\" >1944<\/option><option value=\"1943\" >1943<\/option><option value=\"1942\" >1942<\/option><option value=\"1941\" >1941<\/option><option value=\"1940\" >1940<\/option><option value=\"1939\" >1939<\/option><option value=\"1938\" >1938<\/option><option value=\"1937\" >1937<\/option><option value=\"1936\" 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Patient information \u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0637\u0644\u0628 | Request Date DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 Patient Medical History Form Power of attorney and declaration of consent \u0627\u0633\u0645 \u0627\u0644\u0645\u0631\u064a\u0636 | Patient Name * \u062a\u0627\u0631\u064a\u062e \u0627\u0644\u0645\u064a\u0644\u0627\u062f | Date of Birth DD12345678910111213141516171819202122232425262728293031MM123456789101112YYYY20262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920 \u0627\u0644\u062c\u0646\u0633\u064a\u0629 | Nationality Select [&hellip;]<\/p>","protected":false},"author":1,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"footnotes":""},"class_list":["post-2377","page","type-page","status-publish","hentry"],"blocksy_meta":{"has_hero_section":"disabled","disable_header":"yes","disable_footer":"yes","styles_descriptor":{"styles":{"desktop":"","tablet":"","mobile":""},"google_fonts":[],"version":6}},"_links":{"self":[{"href":"https:\/\/medcoordinate.com\/en\/wp-json\/wp\/v2\/pages\/2377","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/medcoordinate.com\/en\/wp-json\/wp\/v2\/pages"}],"about":[{"href":"https:\/\/medcoordinate.com\/en\/wp-json\/wp\/v2\/types\/page"}],"author":[{"embeddable":true,"href":"https:\/\/medcoordinate.com\/en\/wp-json\/wp\/v2\/users\/1"}],"replies":[{"embeddable":true,"href":"https:\/\/medcoordinate.com\/en\/wp-json\/wp\/v2\/comments?post=2377"}],"version-history":[{"count":157,"href":"https:\/\/medcoordinate.com\/en\/wp-json\/wp\/v2\/pages\/2377\/revisions"}],"predecessor-version":[{"id":2943,"href":"https:\/\/medcoordinate.com\/en\/wp-json\/wp\/v2\/pages\/2377\/revisions\/2943"}],"wp:attachment":[{"href":"https:\/\/medcoordinate.com\/en\/wp-json\/wp\/v2\/media?parent=2377"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}