Hospital Pre-Registration Form
DCR/Dr. Alejandro Lev patient
You can fill this form out right now on this page and then when you click on the "send form now" button at the bottom of this page, it will be automatically sent straight to the registration desk at the Cima Hospital in San Jose, Costa Rica. Now isn't this just a piece of cake?
If you have not yet booked a date for
surgery do not fill out this form.
Contact Didi
at trlwd@aol.com to
book your date. Thanks
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These are required fields
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Email Address
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First Name:
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Last Name:
Middle Name:
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Date of Birth:
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Case Type:
(Medical)
(Surgical)
(Normal Delivery)
(C-Section)
(Chemo)
(Psychiatric)
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Admission Type:
(Out Patient)
(Intensive Care Unit)
(Hospitalization)
(Intermediate Care Unit)
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Estimated Date of Arrival
(Date of Surgery)
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Patient Classification:
Normal
Discount
Agreement
Insurance
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Exact Address:
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Phone Number:
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Age:
*
Sex:
Female
Male
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Religion:
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Martial Status
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Nationality:
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Work Location and Occupation:
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Place of Birth:
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Complete Name of Spouse:
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Complete Name of Father:
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Complete Name of Mother:
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Complete Name of Contact in Case of Emergency:
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Relationship with Contact Person:
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Exact Address of Contact Person:
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Phone Number of Contact Person:
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Complete Name of Person Responsible for Hospital Bills:
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Account Payment:
(How will you be paying your bill?)
Complete Diagnosis:
(where applicable)
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What Procedure will you be having?
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Physicians Name:
*
Patient Passport Number:
Country where Passport was Issued:
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Date Passport Expires:
Please Do NOT submit this form if you have not booked a date for surgery with
Didi
.