Read the terms carefully

I, {Name (Name): 16.3} {Name (Surname): 16.6}, bearer of the identity and electoral card and / or passport No. {{No. ID: 137} {No. of passport: 138}, of nationality {Nationality: 135}, on the day {date_dmy}. I DECLARE UNDER FAITH OATH, I am the sole (sole) liable for any damage caused to me by any omission to the bad information that has been spilled in this document after having carefully read the questions asked by Doctor Fernández Goico, and I understand that hiding any type of medical information from him or his medical staff could put my life and health at risk, as well as the obligation that I have to notify any change or alteration of the information provided here.

Patient's signature


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{Name (Name): 16.3} {Name (Surname): 16.6}