PRE-ADMISIÓN | Del Valle

HOSPITAL PRE-ADMISSION

South Unit

* This form only applies within 48 hours prior to entry.

Patient's data

Name

Date of birth

Religion

Last name

Mother's last name

Cell phone

Place of birth

Country

Condition

City

Nationality

Address

Country

City

Cologne

Condition

Municipality or Alcandía

Postal Code

Street and no.

Home Phone

Responsible for the Patient

Nombre del Responsable

Relación con el Paciente

Apellido Paterno

Correo electrónico

Apellido Materno

Teléfono del Responsable

Address of the Responsible

Calle y núm.

Cologne

City

Postal Code

Home phone

Procedimiento o tratamiento al que se someterá el paciente:

Nombre del Médico Tratante

Teléfono del Médico

Probable Entry Date

Individual or Agreement / Insurer

What phone number do you want us to contact to follow up on your pre-admission, and at what time:

Teléfono de Contacto

I accept privacy policies of issued data

Descarga AQUI las instrucciones para tu pre-admisión.

HOSPITAL PRE-ADMISSION

South Unit

* This form only applies within 48 hours prior to entry.

Patient's data

Place of birth

Address

Responsible for the Patient

Address of the Responsible

What phone number do you want us to contact to follow up on your pre-admission, and at what time:

Notice of Privacy

Términos y condiciones

All rights reserved. Mexico 2020