DATOS DEL PACIENTE:

Nombre y Apellido
Field is required!
Field is required!
Cedula
Field is required!
Fecha
Field is required!
Dirección
Field is required!
Estado Civil
Field is required!
Teléfono
Field is required!
Nacionalidad
Field is required!
Correo
Field is required!
MODALIDAD DE PAGO:
Field is required!
Diagnostico
Field is required!
Teléfono
Field is required!
Compañía de Seguro
Field is required!
Medico Tratante
Field is required!