Mexican Medical Consultation Request

Please Tell Us How To Contact You To Help With you Medical Needs.

Privacy policy: Absolutely none of your information is sold, loaned, rented or otherwise shared with anyone, anywhere other the appropriate physician or dentist or medical staff. Your email is encrypted by this form. We do not ask for any confidential information here, just enough to get an idea of how to contact you and what you need.

Email:

First name: Last Name:

Second patient (if any) First name:

Second patient (if any) Last Name:

We don't need all your phone numbers, just the one or two that are best to reach you if we need to.

OK to call you?

Please just put area code and use dashes 123-456-7891 instead of ( ). Add extension if needed. Don't put +1 or the country code if you live in Mexico. We will figure that out.

Phones: Day: Ext.

Evening : Cell

Best Time To Call: Your Time Zone

Type of medical care needed:

Area of Mexico You're Interested In:

Have you seen a physician/dentist for this?

Do you have your medical records or X-rays? (If you can provide them, it will help us treat you). Timeframe you wish to have procedure done:

In the comments, PLEASE do not use quotes (" ").

Comments (limited to 255 characters - 4 lines) -- If it scrolls, I won't see all your comments. Put them in next box -- Comments2.
Please let us know what sort of work you want done (or think you need). The doctor will determine what is best, but a guideline will help determine how long an appointment or stay to schedule. If you have specific travel dates in mind, please include them.

Comments2

Date in format MM/DD/YYYY:

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