Prof. Dr. Uğur Türe - Medical Evaluation Form

Medical evaluation form

Please complete all required fields.

1) Patient Information Please enter the patient’s personal information.

Patient Status *

New patient - First report/imaging submission

Follow-up Patient

Full name: *

Date of birth : *

Sex : *

Country: *

E-mail address : *

E-mail address 2 :

Phone number : *

Phone number 2 :

2) Medical examination files Please upload the relevant medical files.

Uupload medical images ( MRI - CT - Angiography) * Please select .zip containing your MR-BT-ANJIO.

Upload medical reports (radiology report, discharge summary, and/or pathology report) Please select your radiology, discharge summary, and/or pathology reports.

3) Medical History Please provide details of any previous treatments, if applicable.

Have you had any previous surgery? *

Yes No

Have you received chemotherapy? *

Yes No

Have you received radiotherapy? *

Yes No

Write down the medications you use, if any

4) Symptoms and additional notes Please provide details about your symptoms and any questions you would like to ask the doctor.

Please describe your symptoms *

What would you like to ask the doctor. *