Date: / / Admission am

dd mm yy time: pm

PATIENT INFORMATION
Family Name (Surname) First Name

Age Day of Birth Single Nationality

Male
Civil Married
Sex
/ / Status Divorced
Female
DD MM YYYY Widowed

Home Address
City State

Zip Code Country

Hotel Hotel Phone Number Room Number

Phone Number ( ) Movil

Office Number e.mail

Tyoe of Payment Invoice data / Insurance:

Cash

Amex

Visa / MC

Wire Transfer

"I am personally responsible for the payment of the services provided at HOSPITAL AMBROISE S.A.P.I. DE C.V. and authorize the
hospital to process my credit card within the first 45 days after the service is rendered to recover the total cost of the service. I (We)
owe and will pay to the order of HOSPITAL AMBROISE S.A.P.I. DE C.V. in Puerto Morelos, Q. Roo, on the _____ day of
_______________ of 20___, the amount of $_______________ (___________________________________________________
____________________________) the value of the merchandise that I (We) have received to my full satisfaction.
This promissory note is commercial and is governed by the General Law of Negotiable Instruments and Credit Transactions under its
Article 173, final part, and related articles, as it is not a domiciled promissory note. In case of non-payment of this document on the
due date, I will pay ___% monthly for the time it remains unpaid."

Patient's Signature Responsible Companion today's date:

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Relationship

HOSPITAL AMBROISE S.A.P.I. DE C.V. SM.19, Mza.1, Lt. 1-9, Puerto Morelos, Q. Roo México CP. 77580