MEDICAL CITA

Name *

First Last Name *

Second Last Name

Nationality *

Document *

User *

Password *

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Email *

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Type of Identification

Identification Number

Nombre o Razón Social

Email for copies

Holder name *

Card number *

Month *

Year *

Cool *

Acquired data

Data to be paid

Plan: Clínicas u Hospitales por mes

Amount: $840

VAT (13%): $109.2

Total: $949.2

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