Download PRE-ADMISSION FORM FOR REHABILITATION SERVICES

PRE-ADMISSION FORM FOR REHABILITATION SERVICES
APPLICANT'S FULL NAME:
NIF:
Date of Birth:
Phone Number:
Address:
Email:
Contact person:
NIF:
Relationship:
Phone Number:
Address:
OTHER INFORMATION:
Principal Diagnosis:
Year of Injury:
Insurer:
Current Rehabilitation Center (if applicable):
DOCUMENTATION REQUIRED:
Please attach the copy of the following documents to this form:
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NIF, NIE or Passport.
Healthcare Card (Spanish citizens) / Insurance Card or Policy.
Certificate of disability
Dependency Level Degree / Individual Care Programme.
Updated reports: psychological, social, medical.
Madrid, on [Month] [Day], [Year]
Signature.: ___________________
Camino de Valderribas, 115 / 28038 Madrid
T 91 777 55 44 / M 669 879 846 / F 91 477 61 85
www.medular.org
Centro Concertado con la Consejería de Asuntos Sociales
Inscrita en el Registro de Fundaciones de Madrid en el Tomo IX, nº de Hoja Personal 108 – CIF- G81842130