Hellenic Forums Omogenia - YASOU - Hellenism: <<ΔΕΝ ΕΧΩ ΑΛΛΟ ΧΡΟΝΟ>> ΡΑΔΙΟΜΑΡΑΘΩΝΙΟΣ ΖΩΗΣ...

Contact Name ____________________________ Email
_______________________@_______
Name of individual we can contact on
patients behalf

Phone __________________________________ Fax
_________________________________
Country Code / Area Code / Number
Country Code / Area Code / Number

> This section is to be completed by a Physician that is not a friend or
family member <

* Diagnosis:
___________________________________________________________________

* Date of diagnosis: ____/____/____
Month Day Year

* What treatment modalities has the patient received and corresponding dates?

__________________________________________________________ ____/____
Month Year

__________________________________________________________ ____/____
Month Year

__________________________________________________________ ____/____
Month Year

* Please note any other medical problems this patient may have (Heart,
Lung, GU, GI, CNS):

______________________________________________________________________

______________________________________________________________________

* Current treatment plan being recommended or reason for possible medical
travel:

______________________________________________________________________

* Is patient medically stable for travel: [ ] Yes [ ] No

* Recommend patient obtain: [ ] Mail Review [ ] Treatment

[ ] Consultation Only -
desired dates: ___/___/___ to ___/___/___
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Physician Name ________________________ Physician Signature
________________________

Physician Phone ________________________ Date ___/___/___

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