Today: Saturday, January 18, 2020
Please complete and return admission form and patient history to the hospital.
Reason for the admission and history of present illness.
Medical and Surgical History: List the medical condition / operations performed and date
Please list all medications including complementary medications and bring these to hospital in their original containers.
please fill out the blank by this format: Drug Name - Dose - Frequency / Time
Attach Medication Documents:
Shahid Beheshti Ave, Urmia
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