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Personal Information 
                                
                                
                                
                                
                                
                                
                                
                                    Gender*  
                                    
                                        Select Gender 
                                        
                                            Male 
                                        
                                            Female 
                                        
                                            Other 
                                     
                                
                                
                                
                                    Select Language*  
                                    
                                                                                    Chinese 
                                                                                    English 
                                                                                    Spanish 
                                                                                    Hindi 
                                                                                    Urdu 
                                                                                    Arabic 
                                                                                    Portuguese 
                                                                                    Bengali 
                                                                                    Russian Cyrillic 
                                                                                    Japanese 
                                                                                    German 
                                                                                    Italian 
                                                                                    korean 
                                                                                    Thai 
                                                                                    Polish 
                                                                                    Turkish 
                                                                                    Tamil 
                                                                                    Punjabi 
                                                                                    Telugu 
                                                                                    Marathi 
                                                                                    Swahili 
                                                                                    Indonesian 
                                                                                    French 
                                                                                    Ukrainian 
                                                                                    Romanian 
                                                                                    Dutch 
                                                                                    Greece 
                                                                                    Swedish 
                                                                                    Hungarian 
                                                                                    Norwegian 
                                                                                    Finnish 
                                                                                    Czech 
                                                                                    Slovak 
                                                                             
                                
                                
                                
                                    Date Of Birth*  
                                     
                                
                                
                                    Payment Plan*  
                                    
                                                                                    
                                                ESSENTIAL | 100 
                                                                                    
                                                PREMIUM | 250 
                                                                                    
                                                ELITE | 500 
                                                                                    
                                                Person to Person Consultation | 0 
                                                                             
                                
                                
                                    
Address 
                                
                                
                                
                                
                                    Country*  
                                    
                                                                                    
                                                Afghanistan 
                                                                                    
                                                Albania 
                                                                                    
                                                Algeria 
                                                                                    
                                                American Samoa 
                                                                                    
                                                Andorra 
                                                                                    
                                                Angola 
                                                                                    
                                                Anguilla 
                                                                                    
                                                Antarctica 
                                                                                    
                                                Antigua And Barbuda 
                                                                                    
                                                Argentina 
                                                                                    
                                                Armenia 
                                                                                    
                                                Aruba 
                                                                                    
                                                Australia 
                                                                                    
                                                Austria 
                                                                                    
                                                Azerbaijan 
                                                                                    
                                                Bahamas The 
                                                                                    
                                                Bahrain 
                                                                                    
                                                Bangladesh 
                                                                                    
                                                Barbados 
                                                                                    
                                                Belarus 
                                                                                    
                                                Belgium 
                                                                                    
                                                Belize 
                                                                                    
                                                Benin 
                                                                                    
                                                Bermuda 
                                                                                    
                                                Bhutan 
                                                                                    
                                                Bolivia 
                                                                                    
                                                Bosnia and Herzegovina 
                                                                                    
                                                Botswana 
                                                                                    
                                                Bouvet Island 
                                                                                    
                                                Brazil 
                                                                                    
                                                British Indian Ocean Territory 
                                                                                    
                                                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 
                                                                                    
                                                Republic Of The Congo 
                                                                                    
                                                Democratic Republic Of The Congo 
                                                                                    
                                                Cook Islands 
                                                                                    
                                                Costa Rica 
                                                                                    
                                                Cote D 
                                                                                    
                                                Croatia (Hrvatska) 
                                                                                    
                                                Cuba 
                                                                                    
                                                Cyprus 
                                                                                    
                                                Czech Republic 
                                                                                    
                                                Denmark 
                                                                                    
                                                Djibouti 
                                                                                    
                                                Dominica 
                                                                                    
                                                Dominican Republic 
                                                                                    
                                                East Timor 
                                                                                    
                                                Ecuador 
                                                                                    
                                                Egypt 
                                                                                    
                                                El Salvador 
                                                                                    
                                                Equatorial Guinea 
                                                                                    
                                                Eritrea 
                                                                                    
                                                Estonia 
                                                                                    
                                                Ethiopia 
                                                                                    
                                                External Territories of Australia 
                                                                                    
                                                Falkland Islands 
                                                                                    
                                                Faroe Islands 
                                                                                    
                                                Fiji Islands 
                                                                                    
                                                Finland 
                                                                                    
                                                France 
                                                                                    
                                                French Guiana 
                                                                                    
                                                French Polynesia 
                                                                                    
                                                French Southern Territories 
                                                                                    
                                                Gabon 
                                                                                    
                                                Gambia The 
                                                                                    
                                                Georgia 
                                                                                    
                                                Germany 
                                                                                    
                                                Ghana 
                                                                                    
                                                Gibraltar 
                                                                                    
                                                Greece 
                                                                                    
                                                Greenland 
                                                                                    
                                                Grenada 
                                                                                    
                                                Guadeloupe 
                                                                                    
                                                Guam 
                                                                                    
                                                Guatemala 
                                                                                    
                                                Guernsey and Alderney 
                                                                                    
                                                Guinea 
                                                                                    
                                                Guinea-Bissau 
                                                                                    
                                                Guyana 
                                                                                    
                                                Haiti 
                                                                                    
                                                Heard and McDonald Islands 
                                                                                    
                                                Honduras 
                                                                                    
                                                Hong Kong S.A.R. 
                                                                                    
                                                Hungary 
                                                                                    
                                                Iceland 
                                                                                    
                                                India 
                                                                                    
                                                Indonesia 
                                                                                    
                                                Iran 
                                                                                    
                                                Iraq 
                                                                                    
                                                Ireland 
                                                                                    
                                                Israel 
                                                                                    
                                                Italy 
                                                                                    
                                                Jamaica 
                                                                                    
                                                Japan 
                                                                                    
                                                Jersey 
                                                                                    
                                                Jordan 
                                                                                    
                                                Kazakhstan 
                                                                                    
                                                Kenya 
                                                                                    
                                                Kiribati 
                                                                                    
                                                Korea North 
                                                                                    
                                                Korea South 
                                                                                    
                                                Kuwait 
                                                                                    
                                                Kyrgyzstan 
                                                                                    
                                                Laos 
                                                                                    
                                                Latvia 
                                                                                    
                                                Lebanon 
                                                                                    
                                                Lesotho 
                                                                                    
                                                Liberia 
                                                                                    
                                                Libya 
                                                                                    
                                                Liechtenstein 
                                                                                    
                                                Lithuania 
                                                                                    
                                                Luxembourg 
                                                                                    
                                                Macau S.A.R. 
                                                                                    
                                                Macedonia 
                                                                                    
                                                Madagascar 
                                                                                    
                                                Malawi 
                                                                                    
                                                Malaysia 
                                                                                    
                                                Maldives 
                                                                                    
                                                Mali 
                                                                                    
                                                Malta 
                                                                                    
                                                Man (Isle of) 
                                                                                    
                                                Marshall Islands 
                                                                                    
                                                Martinique 
                                                                                    
                                                Mauritania 
                                                                                    
                                                Mauritius 
                                                                                    
                                                Mayotte 
                                                                                    
                                                Mexico 
                                                                                    
                                                Micronesia 
                                                                                    
                                                Moldova 
                                                                                    
                                                Monaco 
                                                                                    
                                                Mongolia 
                                                                                    
                                                Montserrat 
                                                                                    
                                                Morocco 
                                                                                    
                                                Mozambique 
                                                                                    
                                                Myanmar 
                                                                                    
                                                Namibia 
                                                                                    
                                                Nauru 
                                                                                    
                                                Nepal 
                                                                                    
                                                Netherlands Antilles 
                                                                                    
                                                Netherlands The 
                                                                                    
                                                New Caledonia 
                                                                                    
                                                New Zealand 
                                                                                    
                                                Nicaragua 
                                                                                    
                                                Niger 
                                                                                    
                                                Nigeria 
                                                                                    
                                                Niue 
                                                                                    
                                                Norfolk Island 
                                                                                    
                                                Northern Mariana Islands 
                                                                                    
                                                Norway 
                                                                                    
                                                Oman 
                                                                                    
                                                Pakistan 
                                                                                    
                                                Palau 
                                                                                    
                                                Palestinian Territory Occupied 
                                                                                    
                                                Panama 
                                                                                    
                                                Papua new Guinea 
                                                                                    
                                                Paraguay 
                                                                                    
                                                Peru 
                                                                                    
                                                Philippines 
                                                                                    
                                                Pitcairn Island 
                                                                                    
                                                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 
                                                                                    
                                                Smaller Territories of the UK 
                                                                                    
                                                Solomon Islands 
                                                                                    
                                                Somalia 
                                                                                    
                                                South Africa 
                                                                                    
                                                South Georgia 
                                                                                    
                                                South Sudan 
                                                                                    
                                                Spain 
                                                                                    
                                                Sri Lanka 
                                                                                    
                                                Sudan 
                                                                                    
                                                Suriname 
                                                                                    
                                                Svalbard And Jan Mayen Islands 
                                                                                    
                                                Swaziland 
                                                                                    
                                                Sweden 
                                                                                    
                                                Switzerland 
                                                                                    
                                                Syria 
                                                                                    
                                                Taiwan 
                                                                                    
                                                Tajikistan 
                                                                                    
                                                Tanzania 
                                                                                    
                                                Thailand 
                                                                                    
                                                Togo 
                                                                                    
                                                Tokelau 
                                                                                    
                                                Tonga 
                                                                                    
                                                Trinidad And Tobago 
                                                                                    
                                                Tunisia 
                                                                                    
                                                Turkey 
                                                                                    
                                                Turkmenistan 
                                                                                    
                                                Turks And Caicos Islands 
                                                                                    
                                                Tuvalu 
                                                                                    
                                                Uganda 
                                                                                    
                                                Ukraine 
                                                                                    
                                                United Arab Emirates 
                                                                                    
                                                United Kingdom 
                                                                                    
                                                United States 
                                                                                    
                                                United States Minor Outlying Islands 
                                                                                    
                                                Uruguay 
                                                                                    
                                                Uzbekistan 
                                                                                    
                                                Vanuatu 
                                                                                    
                                                Vatican City State (Holy See) 
                                                                                    
                                                Venezuela 
                                                                                    
                                                Vietnam 
                                                                                    
                                                Virgin Islands (British) 
                                                                                    
                                                Virgin Islands (US) 
                                                                                    
                                                Wallis And Futuna Islands 
                                                                                    
                                                Western Sahara 
                                                                                    
                                                Yemen 
                                                                                    
                                                Yugoslavia 
                                                                                    
                                                Zambia 
                                                                                    
                                                Zimbabwe 
                                                                             
                                
                                
                             
                            
                                
                                    
Medical Information 
                                
                                
                                                                        Choose the Doctor*  
                                    
                                        Select Doctor 
                                                                                                                                                                                
                                                    Carlo  Bulletti 
                                                    
                                                 
                                                                                                                                                                                                                            
                                                    Dominique  de Ziegler 
                                                    
                                                 
                                                                                                                         
                                     
                                    
                                 
                                
                                
                                
                                
                                    Blood group*  
                                    
                                        Select Blood Group 
                                        
                                            A+ 
                                        
                                            O+ 
                                        
                                            B+ 
                                        
                                            AB+ 
                                        
                                            A- 
                                        
                                            O- 
                                        
                                            B- 
                                        
                                            AB- 
                                        
                                            Rh-null (Golden Blood) 
                                        
                                            HH 
                                     
                                
                                
                                
                                
                                
                                
                                    Explain your probelm (10 lines max)*  
                                    
                                 
                                
                                    ask your question (5 lines max) 
                                    
                                 
                                
                                    
Upload your medical documentaton ( Blood tests etc) 
                                 
                                
                                    
                                        Upload your medical documentaton ( Blood tests etc) 
                                
                                
                                
                                
                                    
                                         
                                        Upload Exams
                                     
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                                        Upload JPG/TIFF/PDF/DICOM
                                     
                                    Allowed type is: pdf,jpg,DICOM,TIFF 
                                
                                
                                
                                
                                
                                
                                
                                
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