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- Click ‘Get Form’ to open it in the editor.
- Begin by entering your full name in the 'NOMBRE' field, followed by your address details including 'CALLE', 'APARTAMENTO', and 'CÓDIGO POSTAL'.
- Fill in your contact information, including 'TELÉFONO' and 'CELULAR', along with your date of birth in the format provided.
- Indicate your social security number and gender by selecting the appropriate option.
- Complete the marital status section by circling one of the options: Soltero, Casado, Divorciado, or Viudo.
- Provide insurance details including 'COMPAÑÍA DE SEGURO', 'GRUPO #', and policy number. If applicable, mention the primary insured's name and date of birth.
- Answer questions regarding referrals, main complaints, medical history, and lifestyle habits such as smoking or alcohol consumption.
- Review all sections for accuracy before saving or submitting your completed form.
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