Patient Education Video Series Registration: Oregon
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Full name (first, last) / Nombre completo (primer nombre, apellido)
*
Patient's date of birth / Fecha de nacimiento del paciente
*
Email address /
Correo electrónico
*
Street address / Dirección
City, state and ZIP code / Ciudad, estado y c
ódigo postal
Phone number / Número de teléfono
Select the location where you will receive the procedure / Selecciona el lugar donde recibirá el procedimiento
*
-- Please Select --
Providence Hood River Memorial Hospital
Providence Medford Medical Center
Providence Milwaukie Hospital
Providence Newberg Medical Center
Providence Portland Medical Center
Providence St. Vincent Medical Center
Providence Seaside Hospital
Providence Willamette Falls Medical Center
Surgeon's name / Nombre del cirujano
Procedure type / Tipo de procedimiento
-- None --
Hip (cadera)
Knee (rodilla)
Shoulder (hombro)
I don't have a procedure scheduled (no tengo un procedimiento programado)
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