DoğanCard Application
(Any information provided by filling out the form will be used to plan activities to improve your health. Therefore it is very important to give accurate and complete information.)
Name
Surname
Republic of Turkey Identification Number
Gender Male Female
Date of Birth
Place of birth

Other

Blood type
Height cm
Weight kg
Educational Background
Do you have any allergies? Yes No
Important diseases and surgeries you had
Do you smoke?
No Yes
a Day Package(s)
Regular medications used
Do you have Social Security valid through government of Republic of Turkey?
No SGK Bağ-Kur Emekli San.
Private Insurance
Profession
Your marital status
Married Single
Wedding Anniversary
If you have children write down their birthdays.
Interests / Memberships
Work Address
Home Address
Work Phone 0
Home Phone 0
Mobile Phone 0
E-mail
Delivery Address Home Work
Emergency contact name
Emergency contact phone 0
Do you know Family Medicine practices in Turkey? Yes No
Do you have a Family Doctor? Yes No
 
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