Intake form

Help us serve you better

Name *

Email address *

What procedure will you be undergoing?

Please select at least one option.

Otolaryngology

Dentistry

Oral Surgery

Maxillofacial Surgery

Do you have any allergies?

What medications are you currently taking?

Have you undergone anesthesia before?

What is your age group?

Do you have any pre-existing medical conditions?

How did you hear about our services?

Additional questions or comments

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Dr. med. Abdelhadi Fakhir