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Medical Equipment
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Medical Tourism
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Home
About
Medical Equipment
Services
Medical Tourism
Contact us
APPLICATION
Full Name:
*
Place of birth
Gender
Female
Male
E-mail
*
Date of birth
*
blood type
A+
A-
B+
B-
AB
O+
O-
Adress
Governorate
Street
City / Town
Land Line
Mobile Number
*
Occupation
Employed
Unemployed
Job Title
Treatment
The quality of treatment required
*
Hospital admission
First class
Second Class
Third Class
booking date
Booked in the hotel
Yes
No
Multiple companions
I certify that all of the above information is correct and in the event that it is the contrary, I bear the responsibility of transferring disciplinary penalties by the Company and reserving my entitlements.
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