Bertielliasis

HealthGuard 62™ Form

Patient Name *

Please give accurate information so you are not confused with other patients

Date of Birth (d/m/y) *

Email *

We respect your privacy. Your address will not be given to anyone without your permission. Please note that all correspondence will be via these addresses. Please be sure you can receive email from medical@bsi.international (there is no .com etc.)

Email

Confirm Email

Phone / WhatsApp *

We respect your privacy. BSI does not give personal information to outside parties. We request contact info in the event of schedule changes or emergency situations

Important medical questions *

I have pain in the kidneys
I have hot or burning urine
I have a blood-related disease or frequent bleeding
I am anemic
(If female) I am pregnant or breast feeding
(If female) I am presently menstruating
I have or have been treated for cancer
None of these

Other condition not listed. Please comment...

Where would you like to give blood and urine sample for analysis? *

Jimbaran
Canggu
Ubud
At home / villa / hotel

Requested Day & Time *

IMPORTANT, Please note: we will do our best to give you the requested time slot. Confirmation will be sent via WA or Email.

Date

Time

Where would you like to receive test results? *

Jimbaran
Canggu
Ubud
At home, to be scheduled (extra charge with doctor)
Via email, with scheduled Doctor with the BSI video conference system, max 30 minutes
Via W/A, with scheduled Doctor with the BSI video conference system, max 30 minutes

Requested Day & Time for Test Result *

Date

Time

Member Patient Electro NAD IV Infusion

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