Formulario de Contact

1st last name*

2nd last name

Name *

Date of birth

-- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 -- Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec -- 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020

Address

Postal code

City

Region/Country

Contact phone (1)*

Contact phone (2)

Reason for consultation

Desired dates and time

E-mail *

Code *

Write the code*

I have read and accept the Terms of use

This is to let you know that the data that you provided to us voluntarily will be included in the GENERAL DATA BASE FOR PATIENTS OF BARCELONA MEDICAL GESTIÓ registered in R.G.F.P. of Spanish Association for Data Protection, with the Association being responsible in order to respond to your request for information. In all case and at any moment, you could consult, access, rectify, cancel or disagree with our processing your data by contacting our offices in Barcelona, Córcega 302, 2-4, or to the following e-mail: info@bcm.es or by phone 93 414 06 43