• Step 1 of 8

Hello, please insert a valid e-mail to start this survey *

Select the gender *

Mark if you are male or female

Date of birth *

Select the date of birth from the date field

Symptoms *

Let your symptoms know

Do you take medicine?

What kind of pain do you feel?

  Yes No
Migraine
Nausea
Tremor

Evaluate our clinic

We always try to give our best

How do you rate the rooms in our clinic?

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Comfort
Cleaning
Dimensions