Centro médico Imbanaco

Patient Information

Have you received prior attention in CMI?

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First name(s)*

Last name*

Gender*

Female Male

Date of birth*

Language of preference for the patient:

English Spanish Other

Indicate language

Name of parent or tutor

Address*

Country*

City*

What is your main type of telephone?*

Home Mobile Work

Primary Contact Phone*

Email*

Payment method: *

Self-pay Medical insurance

What is the main medical or diagnostic problem by which you contact us?*

For how long has the patient presented the problem?*

Reason for request:*

Personal appointment with a medical professional Request a query for second opinion Other

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