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Dr Waismann Clinic

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Medical Form

Please provide us with your personal information. This will be treated with total confidentiality.

Personal details
Please enter your surname
Please enter your first name
Please provide your Father's fullname
Please enter the country in which you were born
Please enter your date of birth
/ /
Have you a valid Passport?


Please select your marital status


How many children or dependants do you have?
Please enter the city of your address
Please enter the country where you live
Please provide your home phone number plus international code
Please enter your mobile phone number
Please provide your Fax number
(Required)
Please provide details of your education
Please inform us of your present occupation

Do you have any questions?

Dr Waismann will be pleased to answer any questions you might have on dependency to pain killers such as OxyContin, Suboxone, Methadone, Codeine, Darvocet, Percocet or any other opiate based medication.
Contact us for more information
contact@anrclinic.info
+972-8-67550101