Patient´s Guide

Pre-admission

In order to provide assistance, please fill in the following spaces.

* denota un campo obligatorio

ID card or Passport #*

Last Name:*

Mother´s maiden name:*

Nombre:

Date of birth:*

Correo Electrónico:*

Gender:*

Male Female

Marital Status:*

Single Married Divorced Cohabitation

Address:*

City:

Mobile Phone:

Land line Phone

Treating Doctor:*

Diagnosis:*

Medical Insurance:

¿Have you been hospitalized before?

No Yes

¿If your answer is positive, in what date?

Código CAPTCHA:*