Register

Please choose and fill the appropriate Registration Form.

Self Payer Patients Initial Registration.

Bank Card Data Collection Form

Patient Data and Medical History Collection Form

Patient Data Additional Information or Clarification

Additional or Supplemental Information Option.

Allianz World Wide Care Insured Patients Initial Registration

CIGNA Insured Patients Initial Registration – Adults

CIGNA Insured Patients Initial Registration – Pediatrics

Pediatric Patients Registration

Prescriptions for Medications

Prescriptions for Medications – Registered Patients only

Teleconsultation (Telehealth, Telemedicine) Registration

Emergency Contraception Request

COVID-19 Recovery Certification – Teleconsultation