Pre-admission Form
*Last Name
*Name
*Birth Date
*ID/Passport
*Nationality
*Address
*Phone
*Email
Zone
*Type of Insurance
Insurance company name
La Universal America
La Intercontinental
La Nacional
La Colonial
La Antillana
Servicio Dominicano Salud
Palic
Banco Central
BMI
Alico
Otro
Other
Own Resources
International Insurance
Company
Work Phone Number
Person Responsable
Address
Zone
Phone number
Place of work
* Obligatory