FORMULAIRO DE REVISIÓN PERIÓDICA DEL CLIENTE

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Nombre*
¿Está recibiendo tratamiento médico? De ser el caso, por favor díganos el nombre, dirección y numero telefónico del centro de salud; que tratamiento está recibiendo y quien está pagando por ello?*
¿Está usando medicamento(s) para ayudarse? De ser el caso, cual es el nombre del medicamento(s), dosaje y frecuencia que lo(s) usa y quien está pagando por ello(s)?*
¿Usted ha desarrollado algún nuevo problema(s) que piense que está relacionado con su lesión ocasionada en su trabajo? De ser el caso, explique*
4. ¿Esta trabajando? Si es así, ¿Quién es su empleador?
¿Estaría usted interesado en liquidar su reclamo y recibir una única suma de dinero? De ser el caso, por favor háganos saber.*
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