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Your information is secure and accessible only to you and your designated manager.


Gender
Male
Female
Preferable to connect
Phone call
What's app
Birthday
Month
Day
Year
What would you like to receive?
Do you agree with these recommendations?
Yes
No
Patient's condition
Good
Not severe
Severe
Desired dates
within 1 week
within 2-3 weeks
> 1 month
Do you have an international passport?
Yes
No
Do you have a visa?
Yes
No
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