Register

Please choose and fill the appropriate Registration Form.

Self Payer Patients Initial Registration.

Patient Basic Data Collection Form

Bank Card Data Collection Form

Bank Card Data Collection Form

Patient Data and Medical History Collection Form

Patient Data and Medical History Form

Patient Data Additional Information or Clarification

Additional Information or Clarification

Additional or Supplemental Information Option.

Write and Upload Additional Information

Allianz World Wide Care Insured Patients Initial Registration

Allianz Insured Initial Registration with NO TAJ Card
Allianz Insured Initial Registration with TAJ Card
Allianz Insured Children Initial Registration with TAJ Card

CIGNA Insured Patients Initial Registration – Adults

CIGNA Insured Registration for Adults with Basic Data
CIGNA Insured Registration for Adults with Medical History

CIGNA Insured Patients Initial Registration – Pediatrics

CIGNA Insured Registration for Children

Pediatric Patients Registration

Pediatric Data Collection Form

Prescriptions for Medications

Prescriptions for Medications

Prescriptions for Medications – Registered Patients only

Registered Patients – Prescriptions for Medications

Teleconsultation (Telehealth, Telemedicine) Registration

Teleconsultation Registration

Emergency Contraception Request

Emergency Contraception Request

COVID-19 Recovery Certification – Teleconsultation

COVID-19 Recovery Certification