I want to be a patient

Patient Global Services
Access form for admission

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Have you ever been a patient of the Fundación
Cardioinfantil?



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Gender
M F

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Do you have a problem hearing? Yes No
Do you have a visual problem? Yes No
Do you need a translator? Yes No


(in case the patient is under 18)
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Emergency Notification

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Referal Physician



Treating physician    
 Medical Specialty  City
 
 Country  Telephone
 
 Correo electrónico

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Diagnostics

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* Year
* Diagnostic
* Year
* Diagnostic
* Year
* Diagnostic

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Treatment Received:

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* Year
* Treatment
* Year
* Treatment
* Year
* Treatment

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Estimated date for your travel (DD/MM/YY)    
Physician preference    

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Attach your Clinic history   Attach laboratories   Diagnostic Imaging
   

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Contact person in the IC




International Centre Head Nurse
Phone: +(57)1-6672727 ext 6409, 6405, 6406.
Cell Phone: +(57)3174350553
Email: centrointernacional@cardioinfantil.org