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SOLICITUD DE VERTICALIZADORES/ SOLICITATION FORM
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Fecha de solicitud/ Date of solicitation (mm/dd/yyyy):
MM
/
DD
/
YYYY
Descripción del uso/ Where will the stander be used?
En casa del paciente/ In patient's home
En clínica/ In the clinic
Clear selection
Cantidad de verticalizadores?/ How many need?
Your answer
Pais/ Country
Guatemala
Peru
India
Beliz
Honduras
Kenya
Vietnam
Other:
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Referido por TF, TS, TO... Nombre / Who referred you PT, SW... name?
Your answer
Teléfono / Phone:
Your answer
Organización que solicita / Requesting organization:
Your answer
Dirección de organización/ Address of organization:
Your answer
Como Supo de Parate Conmigo/ How Did You Hear About Stand With Me?
Internet
Mi Organizacion/ My organization
Other:
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