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Registro para participar en la feria de Salud.
This is a form so people can register to get the health scre
enings
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Email
*
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Nombre.
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ciudad.
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Telephone.
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Edad.
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Sexo
Mujer
Hombre
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Tratamientos para quien?
Para mis ninos
Para mis padres
Para mi
Para mi esposa
Other:
Que tipo de problemas de salud tienes?
Your answer
Que tipo de examenes necessitas?
Diabetes
Del corazon
Pression
Cancer
Embarazo
Vacunas para gripe
Vacuna para Covid
Other:
Que horas vas a venir?
Time
:
AM
PM
Tienes aseguranza medica?
Medical
Medicare
Seguro privado
Gustaria de aplicar para servicios medicos gratis.
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Los Angeles En que ciudad vives?
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Algun Comentario?
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