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UMBILICAL HERNIA QUESTIONNAIRE
The following information is essential for assessing your hernia condition prior to surgery. This will help us develop a personalized treatment plan, including the surgical approach. Rest assured, all the information you provide will be kept secure and will never be shared with third parties.
* To learn more about hernias and how we can help, visit our website at
HERNIAISTANBUL.COM
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1 | General Information
Your name
*
Your answer
Who is completing this form?
*
Patient
Patient representative on behalf of the patient
Gender
*
Male
Female
Age
*
Your answer
Nationality
*
Your answer
Occupation
*
Your answer
Phone
Your answer
Email
*
Your answer
Please note
that the evaluation report will be sent to you via email within the next 48 hours. If you don't see it in your inbox, kindly check your spam folder. If you still haven't received it, please ensure to review your spam folder to avoid missing the response.
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