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TAMA Free Clinic Tele Consultation Patient Registration
TAMA Free Clinic Tele Consultation Patient Registration.
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* Indicates required question
TAMA Free Clinic 2020 Details
Patient Last Name
*
Your answer
Patient First Name
*
Your answer
Patient Representative Name
*
Your answer
Contact Number
*
Your answer
Email
*
Your answer
New Patient
*
Yes
No
Requested Date
*
MM
/
DD
/
YYYY
Do you have kind of health insurance? (Travel,Visitor,International)
*
YES
NO
If you have selected NO for above section. Please download the GADPH patient form from below link and complete it and email to
clinic@tama.org
.
https://tama.org/documents/GADPH-PatientForm.pdf
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