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