Preregistro | Hospitales MAC

PERSONAL INFORMATION

FULL NAME*

GENDER*

BIRTH PLACE*

E-MAIL*

KNOWN ALLERGIES*

RELIGION*

ATTACH OFFICIAL ID*

MAX 20MG CAN BE LOADED

BIRTHDATE*

AGE*

PHONE NUMBER*

CURRENT ADRESS*

CHRONIC CONDITION*

HAVE YOU RECEIVED MEDICAL ATTENTION IN A MAC HOSPITAL?:

LANGUAGE

HOSPITAL NAME*

SCHEDULED DATE*

AGREEMENT TYPE*

POLICY NUMBER

DOCTOR'S NAME*

SURGERY PROCEDURE TO BE PERFORMED*

SCHEDULED TIME*

INSURANCE COMPANY

Submit insurance letter

MAX 20MG CAN BE LOADED

TREATING PHYSICIAN'S NAME

FULL NAME*

RELATIONSHIP*

CURRENT ADRESS*

BIRTHDATE*

PHONE NUMBER*

ATTACH OFFICIAL ID

MAX 20MG CAN BE LOADED

ATTACH YOUR TAX STATUS CERTIFICATE

MAX 20MG CAN BE LOADED