We accept most of the PPO Insurance Plans

Please fill in this form. We will get back to you as soon as possible.

Subscriber Full Name *

Date of Birth *

Name of Insurance Plan *

ID Number *

Group Number *

Customer Service Phone Number *

Name of the Patient if Different than Subscriber *

Patient's Date of Birth *

Email *

Phone Number *

I agree with your terms and conditions

Name

Plaza Pacífico Building
10122 José Clemente Orozco
3rd Floor, Office 310
Zona Río, Tijuana