INTAKE FORM

Fill your intake form,
we’ll do the rest.

Personal information

Diagnosed medical conditions

(Diabetes, hypertension, hypothyroidism, etc)

Daily medications

(Including supplements & over counter)

Allergies

Past Surgeries

(Any type; specify approximate date and any complications if applicable)

Somking / Drug use

(Current or past; specify duration, time since quiting, and quantity)

Alcohol consumption

(Frequency per week)

Health concerns/treatment you are seeking

(Condition or Issue You are Seeking Treatment For)

Do you have imaging, blood tests, or other studies available

Additional notes/observations:

YOUR GUIDE TO MEDICAL CARE IN MEXICO

Enter your info below to get your free guide to medica care in Mexico!