Appointments form - Clínica Barraquer

Thanks for choosing us

Through this form you will receive voucher of the appointment with the details of the appointment, the date and the time at which you must present at the Clinic

INTEGRAL APPOINTMENT
DIAGNOSTIC EXAM

INTEGRAL APPOINTMENT

Are you visiting us for the first time? *YesNo

Names:*

Lastname(s):*

Document Type:*

Document Number:*

Date of Birth:*

City:*

Country:*

Email:*

Residence address:

Teléfono:

Mobile phone:*

Does any Prepaid Medicine belong?*YesNo

If you have prepaid medicine service, include in this field the data of your prepaid medicine company (Company, policy number and plan) if you wish to use it.

Select the date range in which you would like your appointment

Since:*

Until:*

Please select the initial date at least five (5) days apart from today's date and the final date at least three (3) days after the initial date.

Reason for consultation:*

If you want to be attended by a particular professional, select:

If you remember the name of the professional who has treated you, fill it out in this part, otherwise leave the space empty.

Optometrist

Ophthalmologist:

If you do not have preference, do not choose or if you wish, consult our medical directory to choose your Ophthalmologist according to your subspecialty that best suits your visual needs.

DIAGNOSTIC EXAM

Was the exam ordering at Barraquer Clinic?*YesNo

Indispensable Requirement: Remember to present the original medical order of the requested exam on the day of your appointment or else it will not be attended.

Names:*

Lastname(s):*

Document Type:*

Document Number:*

Date of Birth: *

City:*

Country:*

Email:*

Residence address:

Phone:

Mobile phone:*

Do you belong to any Prepaid Medicine?*YesNo

If you have prepaid medicine service, include in this field the data of your prepaid medicine company (Company, policy number and plan) if you wish to use it.

Select the date range in which you would like to perform your diagnostic test.

Since:*

Until:*

Please select the initial date at least five (5) days apart from today's date and the final date at least three (3) days after the initial date.

Exam Name:*

Observations: