Referral form | Curaçao Medical Center

"*" indicates required fields

Comments

This field is for validation purposes and should be left unchanged.

Patient data

First name*

Last name*

Address

Date of birth*

ID Number

Phone number*

E-mail address*

Authorized Person

Person assigned by the patient to pick up medical files

First name

Last Name

Address

Date of birth

ID Number

Phone number

E-mail address

Medical treatment in Advent Hospital

Physician’s name*

| Medical treatment in CMC

Physician’s name*

Treatment period*

Required information

CMC Medical file (after November 2019)

SEHOS Medical file (before November 2019)

Medical images (Example: MRI, Rontgen)

Please bring/ send (a copy of) your ID

The undersigned hereby cancels the medical treatment agreement that he/ she has with aforementioned physician as of today. The undersigned is aware that by signing this form, he/ she is no longer a patient of the above- mentioned physician and will therefore be removed from the waiting list. Furthermore, the undersigned gives permission to CMC personnel to provide his/ her medical file to him/ her.

I cancel my treatment agreement as of today*

I cancel my treatment agreement as of today

I give permission to the CMC staff to print out or send my medical file to me*

I give permission to the CMC staff to print out or send my medical file to me

I will receive my file by email

I will pick up my file personally

Upload ID*

Max. file size: 25 MB.

Have some feedback for us?

Use our Compliments and Complaints process to let us know.
In the case of an emergency, call 910