Member Services Patient Questionnaire

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Patient Full Name *

You may be asked to present your BSI Member ID card, or a passport or local ID

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.)

Confirm Email

Phone / WhatsApp *

Please Fully Describe Your Illness or Concern *

When Would You Like an Appointment? *

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

Please choose your location *

Jimbaran (ALL SERVICES)
Canggu (GP SERVICES & INFUSIONS)
Ubud (GP SERVICES & INFUSIONS)

I am requesting ... *

Is there anything else we can do for you ? Choose as many as you like

Explain here if you like ...

Brain Fog & Memory
Dengue Testing & Therapy
Depression & Anxiety
Female Hormones
Hypertension (High Blood Pressure)
Insomnia (Sleep Disorders)
NAD Longevity Therapy, NAD Addictions Therapy
Male Hormones
Parasites Testing & Therapy
Super Bugs / Immunities Enhancement
Smoking Cessation Program
Youth Preservation
STD Testing
Heavy Metals Analysis
Thyroid & Pituitary
Comprehensive Male Hormone Panel
Comprehensive Female Hormone Panel
Lipid Profile
Tumor Marker
Blood Type A B O Rh
Differential Count
Ferritin
Vitamin B12
D-Dimer
Liver Panel
Kidney Panel
AFP Tumor Marker
CEA Tumor Marker
CA-15-3 Tumor Marker
CA 19-9 Tumor Marker
CA 72-4 Tumor Marker
SCC Tumor Marker
HE4 Tumor Marker
CA 125 Tumor Marker

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