IML - Institució de Medicina Lliure

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Inici / Aplication

APPLICATION FOR MEDICAL CARD

To request your medical card you can fill out the fiedls you'll see below.

You can also fill out the Aplication Form (Click here) and send it to us.

The medical card is valid for 12 months from the date of issue. Renewal is automatic, unless the user contact us two months before the expiry date, wich appears at the back of the medical card).

Register online through our website: please fill in the boxes you see below.Once we have received this information, we will contact you to confirm all your details and to proceed to send you your medical card and medical guide.

Data of people who request medical card

Surname 1 *	Surname 2 *	Name *	NIE *	Date of Birth (25-12-1960) *	M/F *

Address / Piso * /

City / town *

Zipcode *

Telephone 1 *

Telephone 2

E-mail

Bank details / Account number

Account Holder *

NIE *

Bank Name *

Account number *

Entity *	Office *	DC *	Account number *

* Autorizo carguen a mi cuenta y hasta nuevo aviso los recibos librados por Institució de Medicina Lliure.

Condiciones y seguridad

* He leido y acepto estas condiciones. Ver condiciones.

SECURITY WORD *

Please type the security word shown in the gray box above.

* Mandatory information is required.

Legal Information

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