LONG QT SYNDROME MULTIGEN PANEL

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—Por favor, elige una opción—Observatorio CampusSanta Fe Campus

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Email*

Phone number*

Select your preferred campus*
—Por favor, elige una opción—Observatorio CampusSanta Fe Campus

Invoice date*

Patient's official ID* If the patient is a minor, please attach a parent or legal guardian's ID. (PDF, JPG)

Email*

Phone number*

Select your preferred campus*
—Por favor, elige una opción—Observatorio CampusSanta Fe Campus

Invoice date*

Patient's official ID* If the patient is a minor, please attach a parent or legal guardian's ID. (PDF, JPG)

Email*

Phone number*

Select your preferred campus*
—Por favor, elige una opción—Observatorio CampusSanta Fe Campus

Date the study was performed*

Patient's official ID* If the patient is a minor, please attach a parent or legal guardian's ID. (PDF, JPG)

Email*

Phone number*

Select your preferred campus*
—Por favor, elige una opción—Observatorio CampusSanta Fe Campus

Prescription or medical order*

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Phone number*

Select your preferred campus*
—Por favor, elige una opción—Observatorio CampusSanta Fe Campus

Invoice to be modified*

Tax ID (RFC)*

Full name or legal business name*

Tax address*

Patient's official ID* If the patient is a minor, please attach a parent or legal guardian's ID.

Note: Invoices are not issued to insurance companies. Please attach your Tax Status Certificate (Constancia de Situación Fiscal).