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Step One

• WHO RECOMMENDED OUR SERCICES TO YOU* Governmental InstituteInsurance CompanyRelative / acquaintance / friendEmbassyEmployer
• Other, please specify: otra opción
• Referral Request *2nd OpinionPhysician ConsultationHospital AdmissionCost Analysis
• 1.Do you have a preference for one of the following hospitals: *Ángeles del CarmenBernardetteCentro Médico Puerta de HierroCountry 2000Lomas ProvidenciaMéxico Americano Real San JoséSan JavierSiloéVersallesNo Preference

Patient Information

Patient's Name: *

Patient's Family Name: *

Gender: *MaleFemale

Permanent Address: *

Date of Birth(Month, Day, Year): *

City: *

Zip or Postal Code: *

Home Telephone: *

Business Telephone: *

E-mail: *

Home Telephone: *

Business Telephone:

Emergency Contact Name:

Contact’s Relation to Patient:

Contact’s Telephone Number:

Clinical Information

Patient Diagnosis (please list all of your diagnoses):

Patient Clinical Status:

Involved Clinical Department / ’s or Specialty / ’s:

Special Request Regarding Diagnosis or Treatment:

Special Consideration or Question Regarding Diagnosis or Treatment:

Requires sending some file?

Referring Physician Name: *

Specialty: *

Patient Services Information

Anticipated Travel Dates to Guadalajara: From *

To: *

Interpreter Services *Yes No

Languages you speak: *

Interpreter Services: *Private RoomSemi-private room (2 or more beds)

Hotel Accommodations *YesNo

Number of guests traveling with you : *

Country: * AbkhaziaAfghanistanAlandAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAscensionAshmore and Cartier IslandsAustraliaAustralian Antarctic TerritoryAustriaAzerbaijanBahamas, TheBahrainBaker IslandBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Antarctic TerritoryBritish Indian Ocean TerritoryBritish Sovereign Base AreasBritish Virgin IslandsBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChina, People's Republic ofChina, Republic of (Taiwan)Christmas IslandClipperton IslandCocos (Keeling) IslandsColombiaComorosCongo, Democratic Republic of the (Congo Kinshasa)Congo, Republic of the (Congo Brazzaville)Cook IslandsCoral Sea IslandsCosta RicaCote d'Ivoire (Ivory Coast)CroatiaCubaCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Islas Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Scattered Islands in the Indian OceanFrench Southern and Antarctic LandsGabonGambia, TheGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHondurasHong KongHowland IslandHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJarvis IslandJerseyJohnston AtollJordanKazakhstanKenyaKingman ReefKiribatiKorea, Democratic People's Republic of (North Korea)Korea, Republic of (South Korea)KosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMidway IslandsMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmar (Burma)Nagorno-KarabakhNamibiaNauruNavassa IslandNepalNetherlandsNetherlands AntillesNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorthern CyprusNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePalmyra AtollPanamaPapua New GuineaParaguayPeruPeter I IslandPhilippinesPitcairn IslandsPolandPortugalPridnestrovie (Transnistria)Puerto RicoQatarQueen Maud LandReunionRomaniaRoss DependencyRussiaRwandaSaint HelenaSaint Kitts and NevisSaint LuciaSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSlovakiaSloveniaSolomon IslandsSomaliaSomalilandSouth AfricaSouth Georgia and the South Sandwich IslandsSouth OssetiaSpainSri LankaSudanSurinameSvalbardSwazilandSwedenSwitzerlandSyriaTajikistanTanzaniaThailandTimor-Leste (East Timor)TogoTokelauTongaTrinidad and TobagoTristan da CunhaTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluU.S. Virgin IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaViet NamWake IslandWallis and FutunaWestern SaharaYemenZambiaZimbabwe

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Note: For self-pay patients requiring hospitalization, payment in advance is required. For some insurers and for embassy cases, we accept letters of guarantee in place of advance payment. If available, please send a detailed clinical summary along with this form.
PLEASE BE SURE TO REVIEW YOUR SELECTIONS CAREFULLY PRIOR TO SEND. WE LOOK FORWARD TO ASSISTING YOU, AND ASK THAT YOU PROVIDE AS MUCH OF THE REQUESTED INFORMATION AS POSSIBLE SO THAT WE MAY SERVE YOU BETTER.