Fill in the following form to request an initial appointment. When you have completed this form, a person from the Fundació IMOR, will contact you to ask for all the additional information which is needed before confirming your initial appointment.

Details of the Patient:
Name:
Surnames:
Date of Birth:
Sex:	Male: Female:
Address:
Town:
Province:
Post Code:
Country:
Telephone:
Fax:
E-mail:

Health Insurance Company:
Belongs to a Health Insurance Company:	Yes: No:
Name of Company:

Referring doctor
Name and surnames:
Telephone:

Patient Diagnosis Information:
Date of diagnosis:

If you wish, you can print out this form and send it by fax to 34 93 434 07 04