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Medical images for life
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Medical images for life
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Medical test booking form

Test choices
personal information
Validation
Test *
IMAG centres *
Inserted Date *
Time period *
Are you covered by Health Insurance or a Healthcare Subsystem?
Which?
 
 
Health Insurance card/Healthcare Subsystem Beneficiary number
 
 
Observations
 
 
* Mandatory Fields.
Clean
Next
Full name*
 
 
Gender *
Address *
 
 
Postcode *
 
 
 
 
Birthdate *
City/Town *
 
 
E-mail *
 
 
Telephone *
 
 
1st time *
I hereby authorise imag to use all the information included in this registration form, according to the applicable legislation, for data storage and processing purposes, and within the scope of marketing and advertising campaigns.
* Mandatory Fields.
Clean
Next
Your form is about to be submited, please confirm your data.
Send


imagem radiobutton I hereby authorise imag to use all the information included in this registration form, according to the applicable legislation, for data storage and processing purposes, and within the scope of marketing and advertising campaigns.
imagem radiobutton seleccionado I hereby authorise imag to use all the information included in this registration form, according to the applicable legislation, for data storage and processing purposes, and within the scope of marketing and advertising campaigns.
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