Dooradarman: Service request Tele-Rehabilitation Service Request Make sure that the provided information is accurate Estimated time to complete: 2 minutes Name of the patient * Name of the patient First First Last Last Biological sex * Female Male Year of birth * Just enter the Year Phone number (with active WhatsApp on it) * Make sure that this number has an active WhatsApp Email (Optional but recommended) Country of residence * Afghanistan Aland Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Ascension Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory British Virgin Islands Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Congo (DRC) Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Islas Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern and Antarctic Lands Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Korea (North Korea) Korea (South Korea) Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar (Burma) Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Northern Mariana Islands Norway Not Listed Oman Pakistan Palau Palestinian Territories (Gaza Strip and West Bank) Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Helena Saint Kitts and Nevis Saint Lucia Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands Spain Sri Lanka Sudan Suriname Svalbard Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste (East Timor) Togo Tokelau Tonga Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu U.S. Virgin Islands Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe State/Province * Type of the main problem * Pain Disability, Weakness, or Loss of Balance Deformity in vertebrae or other joints Other (please specify)Other (please specify) Diagnosis or the chief complaint For example: knee pain, ACL injury, Shoulder tendon rupture, … For how long has the patient had this problem? One day to one Week More than one week to one month More than one month to 6 months More than 6 months to one year More than one year Which service are you requesting for? (You can check more than one) * Personalized exercises through application Reviewing the documents and the problems by a specialist physician: Report Online Visit with a specialist physician Total Fee for the selected services OMR Are there any specific recommended exercises, or comments for this patient? 0 of 2000 max characters Captcha Submit If you are human, leave this field blank. ContinueSubmit Use Shift+Tab to go back