Patient Form

Patient’s Name *

Patient’s Lastname *

Type of Identification: *

Patient’s ID: *

Patient’s Age: *

Country Code *

Phone *

Email *

Do you have an agreement?: *

Surgery: *

Type of Currency *

Do you have a medical referral?:*

Name of attending physician: *

Specialization: *

Time in the OR: *

Type of anesthesia: *

Type of stay: *

Time in the recovery room: *

Biopsy: *

Are special inputs required? *

Other comments:

Patient Self-Service: