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Name First and Last Name

Email address you may also email us at info@buenomedicalclinic.com with this email to confirm your identity if this is your first time using this form

Mobile Number Phone/SMS contact information

Your Daytime Availability office hours are 9am-4:30pm - Your daytime availability (preferred days and time) e.g. Mondays and Tuesdays in the morning

Preferred Pharamacy Where you would like us to fax or send prescriptions

Latest Blood Pressure Reading For those with or at risk for hypertension

Primary Concern reason for visit (optional)

Cervical Cancer Screening Colon Cancer Screening Mammogram / Ultrasound Screening

Diabetes Screening Cholesterol / Dyslipidemia Screening