Formulario de detalles del paciente

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Contacto de emergencia
Comentario

Detalles del paciente

Los campos obligatorios están marcados ^*

Primer nombre ^*

Segundo nombre

Apellido ^*

Correo Electrónico ^*

Número de teléfono ^*

País de nacimiento ^*

Fecha de nacimiento ^*

Parents name ( If patient under 18 )

Dirección^*

Ciudad^*

Estado^*

Código Postal^*

País ^*

Sexo (Asignado al nacer)^*

Masculino

Femenino

Otro

Persona con discapacidad

¿Estás completando este formulariopor otra persona?

Emergency Contact

Required field are marked ^*

Name ^*

Mobile Number ^*

Relationship

Doctor Details

Required field are marked ^*

Do you have a physician

Yes

Is your physician from Health City Cayman Islands

Yes

Physician name

How did you choose Health City Cayman Islands

Refferal

Self

General Health issues

Are you currently suffering from chronic conditions or have you had any serious illnesses or surgeries in the past 5 years?^*

Yes

Details ^*

Medication

Are you taking any medicine including non-prescription medicine?^*

Yes

Medical Name ^*

Dose ^*

Duration ^*

Allergies

Do you have any allergies?^*

Yes

Details ^*

Additional Details

Do you smoke?

Yes

How many in a day?

Do you consume alchohol?

Yes

How frequently?

Are you depressed, anxious, fearful, or belligerent?

Yes

Details

Insurance Details

Do you have health insurance ? ^*

Yes

Health Insurance Company

I.D. Number

Group Number

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