Salud Integral Treatment procedures

Patient and Physician Information

Please complete the form below to provide us with both Patient and Physician contact information.
(Best completed in Google Chrome or Firefox Browser, you may get errors if viewed and completed in Internet Explorer Browser.)

Optionally, you may download, complete and return to us this pdfPDF Version of the questionnaire.
PLEASE NOTE: The Adobe Acrobat Reader or similar is needed to open and view this file.

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  1. Patient Information

  2. Patient Name:*
    Invalid Input
  3. Date Of Birth*
    Please enter your date of birth
  4. Sex*
    What is your sex?
  5. Email:*
    Invalid Input
  6. Address:*
    Invalid Input
  7. Is your shipping address different from your mailing address*
    Invalid Input
  8. Shipping Address:
    Please enter your shipping ad
    (If different from Patient Address) (NO P.O. Boxes)
  9. Home Phone:*
    Please enter your home number
  10. Cell Phone:
    Please enter your home number
  11. Office Phone:
    Please enter your home number
  12. Fax Number:
    Invalid Input
  1. Physician Information

  2. Physician's Name:*
    Please enter your Physician's Name
  3. Specialty:*
    Please enter Physician's specialty
  4. Office Address:*
    Please enter the Physician's Address
  5. Physcian's Phone:*
    Please enter the Physcian's phone number
  6. Physician's Fax:
    Invalid Input
  7. Enter all the characters in the field below.*
    Enter all the characters in the field below.Invalid Input