Fill out the following form to set up an initial appointment. Once completed, a person from Fundació IMOR, will contact the patient to request all the additional information needed before confirming their initial appointment.

Details of Doctor:
Name:
Surnames:
Address
Town:
Province:
Post Code:
Country:
Telephone:
Fax:
E-mail:

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

Patient Diagnosis Information:
Date of diagnosis:
The patient is referred to a specific doctor:
Name of the doctor:

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